[Evaluation of the "TeleCOVID Hesse" project after 1 year in operation]

BACKGROUND

The SARS-CoV‑2 pandemic posed unexpected challenges for hospitals worldwide and in addition to the supply emergency, simultaneously caused a high pressure to innovate. Due to the high number of cases of COVID-19 patients requiring intensive care, structured networking of hospitals gained particular importance. The tele-ICU communication platform TeleCOVID was developed to improve the quality of intensive care both by enabling teleconsultations and by supporting patient transfers.

OBJECTIVE

The present study aimed to survey user experiences with TeleCOVID. The study investigated the extent to which the app is used, the user experiences of the participating hospitals, and the resulting implications for the further development of the telemedicine application.

MATERIAL AND METHODS

A user survey was conducted in May 2022 using an online questionnaire. The survey contained both closed and open questions with a free text field. It was sent via the Hessian Ministry of Social Affairs and Integration (HMSI). All 135 hospitals in Hesse were contacted by e‑mail and invited to participate in the study. The results of the closed questions were analyzed using descriptive statistics, and the results of the open questions were clustered and thematically summarized using qualitative content analysis.

RESULTS

The study showed that TeleCOVID was used primarily for transfer requests, followed by the need for a treatment consultation without a transfer request. Most often, ECMO treatment or treatment in a hospital of a higher care level was required. The content analysis showed that users particularly rated the possibility of a data protection-compliant and structured transfer of patient data as advantageous. It is also worth mentioning that in almost 25% of the cases a transfer of patients could be prevented by TeleCOVID. Disadvantages frequently mentioned by respondents were the lack of connection to the electronic hospital information system, the increased time required for the registration process, and the poor primary accessibility of contact persons.

CONCLUSION

In a further development of the application the connection to the electronic hospital information system should be considered particularly urgent. In addition, the time expenditure should be reduced by a simplified login process. Due to interface barriers, an alternative data infrastructure would also be conceivable to create interoperability. The introduction of a web client could also increase usability. The main beneficiaries of hospital networking are physicians and patients in a context associated with a high workload and specific medical issues. Continuation and expansion of the app to intensive care medicine and beyond are therefore recommended. In further studies on the project, personal interviews with decision makers could be useful to conduct a more targeted needs analysis.

[Increased revenues from secondary diagnoses : A comparison from dermatology, ophthalmology, and infectious diseases]

BACKGROUND

Hospital revenues generated by diagnosis-related groups (DRGs) are in part dependent on the coding of secondary diagnoses. Therefore, more and more hospitals trust specialized coders with this task, thereby relieving doctors from time-consuming administrative burdens and establishing a highly professionalized coding environment. However, it is vastly unknown if the revenues generated by the coders do indeed exceed their incurred costs.

METHODS

Coding data from the departments of dermatology, ophthalmology, and infectious diseases from Rostock University Hospital from 2007-2016 were analyzed for the effects of secondary diagnoses on the resulting DRG, i. e., hospital charges.

RESULTS

Ophthalmological case were highly resistant to the addition of secondary diagnoses. In contrast, adding secondary diagnoses to cases from infectious diseases resulted in 15% higher revenues. Although dermatological and infectious cases share the same sensitivity to secondary diagnoses, higher revenues could only rarely be realized in dermatology, probably owing to a younger, less multimorbid patient population.

CONCLUSION

Except for ophthalmology, trusting specialized coders with clinical coding generates additional revenues through the coding of secondary diagnoses which exceed the costs for employing these coders.

Effects of the Cardio First AngelTM on chest compression performance

BACKGROUND

Survival rates of out-of-hospital cardiac arrest remain poor. Bystander cardiopulmonary resuscitation (CPR) is crucial for survival and feedback devices could improve its quality.

OBJECTIVE

We investigated the quality of chest compression when using the Cardio First AngelTM (CFA) feedback device compared to standard basic life support (BLS). The analysis focused on laymen.

METHODS

Laymen without (n= 43) and with (n= 96) explanation of the device, medical students (n= 128) and medical staff (n= 27) performed 60 seconds of standard versus assisted chest compression using the CFA on a resuscitation manikin. Compression frequency, depth and position were analyzed according to current guidelines.

RESULTS

Laymen showed significantly better success rates regarding correct compression depth when using the CFA (23.3% vs. 55.8%, p= 0.004 and 25.0% vs. 52.1%, p< 0.001, laymen without and with explanation of the device, respectively). Medical students likewise improved (22.7% vs. 42.2%, p= 0.004). Hand positioning was 100% correct in all groups with the device. Improvement in frequency yielded by the CFA was more pronounced for probands with fears of contact (p= 0.02). The benefit of using the device did not differ significantly in laymen with or without explanation.

CONCLUSIONS

Chest compression as performed by laymen was significantly improved with regard to compression depth when using the CFA for guidance and feedback. With the device, no cases of incorrect hand positioning occurred in any group.

Remote ECLS-Implantation and Transport for Retrieval of Cardiogenic Shock Patients

OBJECTIVE

Extracorporeal life support (ECLS) emerges as a salvage option in therapy refractory cardiogenic shock but is limited to highly specialized tertiary care centers. Critically ill patients are often too unstable for conventional transport. Mobile ECLS programs for remote implantation and subsequent air or ground-based transport for patient retrieval could solve this dilemma and make full-spectrum advanced cardiac care available to patients in remote hospitals in whom shock otherwise might be fatal.

METHODS

From December 2012 to March 2016, 40 patients underwent venoarterial ECLS implantation in remote hospitals with subsequent transport to our center and were retrospectively analyzed. The mobile ECLS team was available 24/7, implantation was performed percutaneously bedside, and compact support systems designed for transport were used.

RESULTS

Twenty percent of the patients were female; the mean age was 55 ± 10 years, and the mean Interagency Registry for Mechanically Assisted Circulatory Support score was 1.3 ± 0.5. Patient retrieval was accomplished via ground-based (n = 29, 72.5%, mean distance = 27.9 ± 29.7 km [range, 5.6-107.1 km]) or air (n = 11, mean distance = 62.4 ± 27.2 km [range, 38.9-116.4 km]) transport. No ECLS-related complications occurred during transport. The ECLS system could be explanted in 65.0% (n = 26) of patients, and the 30-day survival rate was 52.5% (n = 21).

CONCLUSION

Remote ECLS implantation and interfacility transport on ECLS are feasible and effective. Interdisciplinary teams and full-spectrum cardiac care are essential to achieve optimal outcomes. Rapid-response ECLS networks have the potential to substantially increase the survival of cardiogenic shock patients.

Immediate, Early and Late Failure after Transcatheter Aortic Valve Implantation: How to Deal with the Inoperable?

BACKGROUND

Currently, the use of transcatheter aortic valve implantation (TAVI) is constantly increasing, whilst cardiosurgical back-up varies substantially. Besides immediate conversion to surgical aortic valve replacement (SAVR) for periprocedural complications, SAVR for TAV failure may be necessary within the early or late post-implant course. The etiology, incidence, risk-stratification, management and outcome for both scenarios are largely unclear. The study aim was to provide details of the authors' experience of SAVR after the failure of TAVI at a single institution.

METHODS

Nineteen patients (14 males, five females) underwent SAVR after TAVI at the authors' institution between June 2008 and December 2015. The patients' initial EuroSCORE II was 8.54 ± 9.81. In eight cases (42%; 50% transfemoral) an immediate conversion was necessary due to paravalvular leakage and insufficiency (n = 1), valve-malpositioning (n = 1), valve dislocation (n = 3), valve-trapping in mitral chordae (n = 1), and annular rupture (n = 2). The 50% transfemoral EuroSCORE II was 19.06 ± 8.61. In 11 patients transcatheter valve failure occurred at a mean of 18 ± 17 months after TAVI (two patients with structural valve failure and one with severe paravalvular leakage, seven with prosthetic valve endocarditis, and one patient with aortic aneurysm); the mean EuroSCORE II was 13.42 ± 13.06.

RESULTS

For immediate conversion, the cardiopulmonary bypass (CPB) time and aortic cross-clamp time were 104 ± 40 min and 60 ± 16 min, respectively. Concomitant procedures were necessary in two patients, one patient required hypothermic circulatory arrest (HCA) and one died intraoperatively. For early and late failure, the CPB and cross-clamp times were 115 ± 32 min and 82 ± 20 min, respectively. HCA was necessary in one patient, and concomitant procedures in seven patients. The 30-day survival was 63% for immediate SAVR and 100% for early and late SAVR, even though one more patient died on postoperative day 31 after immediate SAVR. Besides, the longest follow up periods were 29 ± 15 months and 19 ± 14 months for immediate and early/late failure, respectively. In both groups, one patient died from cardiovascular-related causes, and one from non-valve-related causes.

CONCLUSIONS

SAVR after previous TAVI will become increasingly relevant. Due to the increasing use of TAVI in medium- or lower-risk patients, adequate strategies must be established since, in comparison to multimorbid patients, not taking action in these patients is not an option. Due to potentially high-risk patients and unique technical implications, SAVR after TAVI differs from conventional (redo) AVR. Under optimal conditions, acceptable survival rates can be achieved, but effective interdisciplinary approaches are essential.

Root Replacement for Graft Infection Using an All-Biologic Xenopericardial Conduit

BACKGROUND AND AIM OF THE STUDY

The management of graft infection following ascending aortic replacement (AAR) and/or aortic valve replacement (AVR) with destruction of the root remains a challenge. Besides technical issues, the choice of graft material is controversial. The study aim was to investigate the initial results of aortic root replacement (ARR) as redo-surgery for infection using the xenopericardial all-biologic conduit (BioIntegral) as an alternative to a homograft or prosthetic material.

METHODS

Between February 2013 and January 2015, a total of 18 consecutive patients (16 males, two females; mean age 61 ± 14 years) were reoperated on for infection at a mean of 55 ± 61 months (range: 3 to 219 months) following previous AVR (n = 6), supracoronary aortic replacement (SAR, n = 2), AVR + SAR (n = 1), root replacement (n = 7), and root reconstruction (n = 2). Two patients (11%) had undergone more than one previous cardiac operation. Signs of infection were seen on computed tomography (CT) scanning in 17 patients (94%). Additional 18F-FDG PET-CT was performed in nine patients (50%).

RESULTS

The cardiopulmonary bypass and crossclamp were 289 ± 77 min and 187 ± 59 min, respectively. Hypothermic circulatory arrest (HCA) + selective antegrade cerebral perfusion (SACP) was necessary in nine patients (50%) and concomitant procedures in 11 (61%). Postcardiotomy extracorporeal life support (ECLS) was necessary in five patients, and renal replacement therapy in eight. One patient died intraoperatively, and the overall 30-day mortality was 22% (n = 4) secondary to multi-organ failure. Risk factors for mortality were myocardial failure requiring ECLS (p = 0.02) and the need for root replacement following previous isolated AVR (p = 0.05). The mean follow up was 12 ± 5 months. Early graft reinfection occurred in one patient (6%), and another presented with pleural empyema without evidence of persisting conduit infection. Thus, freedom from graft reinfection was 94%. No case of structural valve deterioration was seen.

CONCLUSIONS

Aortic root replacement using a xenopericardial conduit in patients with graft infection is technically feasible. Hemodynamics and surgical handling are comparable to that of homografts, but the off-the-shelf availability favors this approach. Mortality was substantial but comparable to that of other series and grafts, with low reinfection rates. Long-term outcome regarding the eradication of infection and durability of the graft remains to be demonstrated.

The Impact of Pre-Operative Malperfusion on Outcome in Acute Type A Aortic Dissection: Results From the GERAADA Registry

BACKGROUND

Malperfusion adversely affects outcomes in patients with acute type A aortic dissection, but reliable quantitative data are lacking.

OBJECTIVES

The aim of this study was to analyze the impact of various forms of malperfusion on early outcome.

METHODS

A total of 2,137 consecutive patients enrolled in GERAADA (German Registry for Acute Aortic Dissection Type A) who underwent surgery between 2006 and 2010, of whom 717 (33.6%) had any kind of pre-operative malperfusion, were retrospectively analyzed.

RESULTS

All-cause 30-day mortality was 16.9% and varied substantially according to the number of organ systems affected by malperfusion (none, 12.6%; 1 system, 21.3%; 2 systems, 30.9%; 3 systems, 43.4%; p < 0.001). Pre-operative cerebral malperfusion, comatose state, peripheral malperfusion, visceral malperfusion, involvement of supra-aortic branches, coronary malperfusion, and renal malperfusion were all independent predictors of developing any post-operative malperfusion syndrome. When survival was considered, age, peripheral malperfusion, involvement of supra-aortic branches, coronary malperfusion, spinal malperfusion, a primary entry in the descending aorta, and pre-operative comatose state were independent predictors, again with increasing significance.

CONCLUSIONS

Malperfusion remains a severe clinical condition with strong potential for adverse outcomes in patients undergoing surgery for acute type A aortic dissection. The GERAADA registry suggests that the impact of the number of organs involved and the type of malperfusion on outcome differs substantially. Introducing an appropriate classification system, such as "complicated" and uncomplicated" acute type A aortic dissection, might help predict individual risk as well as select a surgical strategy that may quickly resolve malperfusion.

Diagnosis of coronary affection in patients with AADA and treatment of postcardiotomy myocardial failure using extracorporeal life support (ECLS)

BACKGROUND

Myocardial ischemia due to concomitant coronary artery disease (CAD) or coronary dissection in patients with acute aortic dissection type Stanford A (AADA) is associated with myocardial failure and poor outcomes. Preoperative coronary angiography in this group of patients is still debated. The use of CT scan to diagnose coronary affection along with the establishment of high-pitched dual-spiral CT protocols are essential for improving outcomes.

METHODS

We retrospectively analyzed six AADA patients with heart failure who were treated using extracorporeal life support (ECLS). Options for diagnosing coronary affection and different therapeutic strategies for postcardiotomy cardiogenic shock in this patient cohort are discussed.

RESULTS

Retrospective review of CT images showed coronary abnormalities in 83% (n=5). Four patients (67%) underwent unplanned coronary artery bypass grafting (CABG). ECLS was instituted in 67% (n=4) due to left heart failure and in 33% (n=2) due to right heart failure. Thirty day mortality was 67% (n=4). The two patients that received ECLS for right ventricular support survived and both had undergone CABG.

CONCLUSION

Besides preoperative evaluation of the extent of the dissection, focus on coronary affection in CT-scans helps to triage the operative procedure. Hybrid operating rooms allow for immediate interventional and/or surgical treatment and enable for immediate control of revascularization results. The use of ECLS over other types of ventricular support systems may allow for myocardial recovery in selected cases.

When all else fails: extracorporeal life support in therapy-refractory cardiogenic shock

OBJECTIVES

No guidelines for mechanical circulatory support in patients with therapy-refractory cardiogenic shock and multiorgan failure including ongoing cardiopulmonary resuscitation (CPR) exist. To achieve immediate cardiopulmonary stabilization, we established an interdisciplinary concept with on-site percutaneous extracorporeal life support (ECLS) implantation.

METHODS

From February 2012 to November 2014, 96 patients were deemed eligible for ECLS implantation. Establishing ECLS was successful in 87 patients (mean age 54 ± 13 years, 16% female, initial flow 4.4 ± 0.9 l/min). Aetiologies included acute coronary syndromes (n = 52, 60%), cardiomyopathies (n = 25, 29%) and other pathologies. Fifty-nine patients (68%) had been resuscitated, and in 27 (31%), implantation was performed during CPR; 11 patients (13%) were awake at implantation and 20 (23%) underwent implantation in the referring hospital.

RESULTS

Metabolic parameters differed in non-survivors versus survivors before ECLS implantation (pH 7.15 ± 0.23 vs. 7.27 ± 0.18, P = 0.007; lactate levels 10.90 ± 6.00 mmol/l vs. 8.79 ± 5.78 mmol/l, P = 0.091) and 6 h postimplantation (pH 7.27 ± 0.11 vs. 7.37 ± 0.11, P < 0.001; lactate levels 10.19 ± 5.52 mmol/l vs. 5.52 ± 4.17 mmol/l, P < 0.001). Altogether 44 patients could be weaned, and 9 were bridged to assist device implantation and 1 to heart transplantation. The mean time of support was 6 days, and the 30-day survival rate was 47% (n = 41).

CONCLUSIONS

ECLS serves as a bridge-to-decision and bridge-to-treatment device. Our interdisciplinary ECLS programme achieved acceptable survival of critically ill patients despite a substantial percentage of patients having been resuscitated and no absolute exclusion criteria. Further studies defining inclusion- and exclusion criteria might additionally improve outcome.

Aortic Valve Replacement in Patients with End-Stage Liver Disease: A Modified Perfusion Concept in High-Risk Patients

BACKGROUND AND AIM OF THE STUDY

Cardiac surgery with the use of cardiopulmonary bypass in patients with end-stage liver disease is associated with a high risk of postoperative morbidity and mortality due to bleeding, and a high incidence of bacterial infection with associated secondary complications. Minimized extracorporeal perfusion circuits (MECCs) with a lower priming volume, reduced foreign surface area, and interdisciplinary preoperative and postoperative treatment may address these negative effects and improve patient outcomes. The study aim was to evaluate the feasibility of the MECC and optimized supportive therapy in patients with advanced-stage liver cirrhosis.

METHODS

Seven consecutive male patients (median age 56 years; range 54-67 years) with hepatic cirrhosis (Child-Pugh score B, median Model of End-stage Liver Disease (MELD) score 14; range 8-26) underwent aortic valve replacement (AVR) using MECC. Supportive preoperative and postoperative management included digestive decontamination, antioxidant supplements, and adjusted anti-infective therapy.

RESULTS

All patients survived the hospital course, with 30-, 60-, and 90-day mortality of 0%. The median intensive care unit and in-hospital lengths of stay were 3 days (range: 1-5 days) and 13 days (range: 5-18 days), respectively. One patient required reexploration due to bleeding, and another suffered from a seizure without permanent neurologic deficits. No patient required new-onset hemodialysis. At a median follow up of 22 months (range: 2-46 months) all patients were alive but displayed only minor improvements in cardiac symptoms (median NYHA class III (range: II-III) at baseline versus II (range: II-III) postoperatively) and hepatic symptoms.

CONCLUSION

Conventional AVR in patients with advanced-stage liver cirrhosis using MECC and optimal medical treatment is feasible. Further studies are required to evaluate the impact of alternative interventional techniques in this high-risk cohort.

[Acute jaw-thoracic pain and syncope in a 41-year-old man]

A 41-year-old physically active man with no significant past medical history presented with sudden thoracic pain. The patient was referred to the next tertiary care hospital. A CT scan showed an ectasia of the ascending aorta with irregularities of the aortic wall without dissection. Despite initial refusal, the patient was referred to a university hospital with experience in aortic surgery. A triphase ECG-synchronized cardiothoracic flash protocol performed on a 256 line CT scanner confirmed an aortic intramural hematoma and a covered aortic perforation. Shortly afterwards the patient collapsed and had to be resuscitated.

An experimental model of myocardial infarction and controlled reperfusion using a miniaturized cardiopulmonary bypass in rats

OBJECTIVES

Different revascularization strategies for patients with acute myocardial infarction (AMI) exist. It remains unclear whether ventricular unloading using cardiopulmonary bypass (CPB) or extracorporeal life support (ECLS) has an impact on early postischaemic ventricular function. Here, we report on the results of an approach using a miniaturized CPB in a well-established animal model of AMI.

METHODS

In a randomized fashion, 30 male Wistar rats were assigned to temporary left anterior descending (LAD) ligation (30 min) followed by 180 min of reperfusion either with or without 60 min of CPB (70 ml/min, 36°C). The CPB circuit consisted of a venous reservoir, a peristaltic roller pump and a membrane oxygenator with heat exchanger. Cardiac function was measured at 60 and 120 min after reperfusion (F60, F120) using a conductance catheter.

RESULTS

The mortality rate was 37% (11/30). Thus, 19 animals could be included into the analysis (8 CPB). The mean cardiac output did not differ between the groups at F60 [63 ± 29 vs 54 ± 25 ml/min (CPB), P = 0.56] and F120 [73 ± 27 vs 53 ± 24 ml/min (CPB), P = 0.21]. During reperfusion, the mean left ventricular ejection fraction (LVEF) was stable in both the control (F60 37 ± 5% vs F120 33 ± 8%, P = 0.42) and the CPB groups (F60 52 ± 11% vs F120 51 ± 13%, P = 0.71). CPB animals had a significantly better LVEF after reperfusion (F60 P = 0.007, F120 P = 0.01).

CONCLUSIONS

In this animal model of AMI, the establishment of CPB resulted in a significantly better LVEF in comparison with conventional reperfusion only. This beneficial effect may have an impact on revascularization strategies and timing in patients presenting with AMI in the future.

Percutaneous extracorporeal life support for patients in therapy refractory cardiogenic shock: initial results of an interdisciplinary team

OBJECTIVES

Therapy refractory cardiogenic shock is associated with dismal outcome. Percutaneous implantation of an extracorporeal life support (ECLS) system achieves immediate cardiopulmonary stabilization, sufficient end-organ perfusion and reduction of subsequent multiorgan failure (MOF).

METHODS

Forty-one patients undergoing percutaneous ECLS implantation for cardiogenic shock from February 2012 until August 2013 were retrospectively analysed. Mean age was 52 ± 13 years, 6 (15%) were female. Mean pH values obtained before ECLS implantation were 7.15 ± 0.24, mean lactate concentration was 11.7 ± 6.4 mmol/l. Levels obtained 6 h after ECLS implantation were 7.30 ± 0.14 and 8.7 ± 5.0 mmol/l, respectively. In 23 patients (56%) cardiogenic shock resulted from an acute coronary syndrome in 13 (32%) from cardiomyopathy, in 5 (12%) from other causes. Twenty-seven (66%) had been resuscitated, in 14 (34%) implantation was performed under ongoing cardiopulmonary resuscitation (CPR). Of note, 97% of the acute coronary syndrome patients underwent percutaneous coronary intervention (PCI) either before ECLS implantation or under ECLS support. Extracorporeal life support implantation was performed on scene (Emergency Department, Cath Lab, Intensive Care Unit) by a senior cardiac surgeon and a trained perfusionist, in 8 cases (20%) in the referring hospital.

RESULTS

Thirty-day mortality was 51% [21 patients, due to MOF (n = 14), cerebral complications (n = 6) and heart failure (n = 1)]. Logistic regression analysis identified 6-h pH values as an independent risk factor of 30-day mortality (P < 0.001, OR = 0.000, 95% CI 0.000-0.042). Neither CPR nor implantation under ongoing CPR resulted in significant differences. In 26 cases (63%), the ECLS system could be explanted, after mean support of 169 ± 67 h. Seven of these patients received cardiac surgery [ventricular assist device implantation (n = 4), heart transplantation (n = 1), other procedures (n = 2)].

CONCLUSIONS

Due to the evolution of transportable ECLS systems and percutaneous techniques implantation on scene is feasible. Extracorporeal life support may serve as a bridge-to-decision and bridge-to-treatment device. Neurological evaluation before ventricular assist device implantation and PCI under stable conditions are possible. Despite substantial mortality, ECLS implantation in selected patients by an experienced team offers additional support to conventional therapy as well as CPR and allows survival in patients that otherwise most likely would have died. This concept has to be implemented in cardiac survival networks in the future.

Emergency cesarean section due to acute aortic dissection type A (Debakey I) without Marfan syndrome: a case report and review of the literature

BACKGROUND

Acute aortic dissection during pregnancy is an uncommon but important emergency due to its lethal risk to both mother and child. The dissection usually involves the ascending aorta or the aortic arch. Although additional affection of the descending aorta up to bifurcation is possible, further increasing the risk of organ malperfusion, full-length aortic dissection (DeBakey I) is known to be very rare. Dissection during pregnancy has been reported predominantly in combination with Marfan syndrome. Acute aortic dissection Stanford type A (AADA) DeBakey I during pregnancy without signs of Marfan syndrome as a warning signal is very uncommon in the current literature.

OBJECTIVES

The etiology, diagnosis, differential diagnosis, and management of this rare disease are discussed in relation to the current literature.

CASE REPORT

We report the case of an athletic 34-year-old woman in the third trimester of pregnancy, without history of previous diseases, who presented to our Emergency Department after collapsing. In the resuscitation department, an emergency cesarean section was performed due to the start of circulation failure in the mother. Computed tomography scan revealed a severe aortic dissection starting from 1 cm distal the aortic valve over the full length up to the iliac arteries, involving the brachiocephalic and carotid arteries up to the level of the larynx. Emergency replacement of the ascending aorta and the aortic arch was performed. Both the mother and baby survived and were doing well 1 year postoperatively.

CONCLUSION

This alarming result of AADA (DeBakey I) in late pregnancy without obvious warnings such as Marfan syndrome illustrates the importance of performing early imaging in similar cases.

Immediate surgical coronary revascularisation in patients presenting with acute myocardial infarction

Background

The number of patients presenting with acute myocardial infarction (AMI) and being untreatable by interventional cardiologists increased during the last years. Previous experience in emergency coronary artery bypass grafting (CABG) in these patients spurred us towards a more liberal acceptance for surgery. Following a prospective protocol, patients were operated on and further analysed.

Methods

Within a two year interval, 127 patients (38 female, age 68±12 years, EuroScore (ES) II 6.7±7.2%) presenting with AMI (86 non-ST-elevated myocardial infarction (NSTEMI), 41 STEMI) were immediately accepted for emergency CABG and operated on within six hours after cardiac catheterisation (77% three-vessel-disease, 47% left main stem stenosis, 11% cardiogenic shock, 21% preoperative intraaortic balloon pump (IABP), left ventricular ejection fraction 48±15%).

Results

30-day-mortality was 6% (8 patients, 2 NSTEMI (2%) 6 STEMI (15%), p=0.014). Complete revascularisation could be achieved in 80% of the patients using 2±1 grafts and 3±1 distal anastomoses. In total, 66% were supported by IABP, extracorporal life support (ECLS) systems were implanted in two patients. Logistic regression analysis revealed the ES II as an independent risk factor for mortality (p<0.001, HR 1.216, 95%-CI-Intervall 1.082-1.366).

Conclusions

Quo ad vitam, results of emergency CABG for patients presenting with NSTEMI can be compared with those of elective revascularisation. Complete revascularisation obviously offers a clear benefit for the patients. Mortality in patients presenting with STEMI and cardiogenic shock is substantially high. For these patients, other concepts regarding timing of surgical revascularisation and bridging until surgery need to be taken into consideration.

Elephant trunks in aortic surgery: fresh and frozen

Aneurysmal diseases are often silent but can cause potentially life-threatening complications in cases of dissection or rupture. Surgical strategies depend on the involved part of the aorta and frequently require extracorporeal circulation and circulatory arrest. From data available from the Centers for Disease Control and Prevention, aneurysm disease is the 18th most common cause of death in all individuals, and the incidence is certain to increase as our population ages. This article discusses different treatment options introduced in the past few decades to address multifocal pathologic conditions of the thoracic aorta. These include the conventional elephant trunk procedure introduced by Hans Borst in 1983, with several modifications, and also hybrid procedures combining open surgical and endovascular techniques: the so-called frozen elephant trunk. Advantages and drawbacks of both techniques will be discussed based on personal and practical perspectives, with specific mention of the elephant trunk procedure in acute aortic dissections.

Minimally invasive aortic valve replacement with self-anchoring Perceval valve

BACKGROUND AND AIM OF THE STUDY

Although minimally invasive aortic valve replacement (AVR) has been proposed to cause less morbidity in patients, it still has not seen broad application. The study aim was to evaluate the implantation of the self-anchoring aortic valve (Perceval S; Sorin) via a mini-sternotomy.

METHODS

As a part of a multicenter, European, prospective, non-randomized, clinical trial, 35 patients (30 females, five males; mean age 80 +/- 4 years) with isolated aortic valve stenosis (mean gradient 48 +/- 21 mm Hg) were operated on at the authors' center. Perceval S self-anchoring valves were implanted following a mini-sternotomy, extracorporeal circulation (ECC), aortic cross-clamping, cardioplegic arrest and removal of the calcified native valve. The mean EuroSCORE and STS score were 12 +/- 9% and 4 +/- 2%, respectively.

RESULTS

There were no failures of deployment, and nor was there any intra-procedure or 30-day mortality. The mean ECC-time was 70 +/- 24 min, and cross-clamp time 34 +/- 10 min. The valve implantation time was 9 +/- 5 min. Perioperative echocardiography revealed no significant aortic insufficiency or paravalvular leakage. The postoperative mean gradient was 16 +/- 6 mmHg. At follow up, there was no paravalvular leakage or significant valvular insufficiency. No migration or dislodgement of the prosthesis occurred.

CONCLUSION

This trial highlights the advantages of the Perceval S self-anchoring valve which, technically is a more reproducible alternative for minimally invasive AVR. As the valve does not need to be sutured, the limited exposure is not a disadvantage even in patients with calcified or small aortic roots. This also potentially reduces the cross-clamp and ECC-times. This valve may enable a broader application of minimally invasive AVR.

Advanced age: a contraindication for triple-valve surgery?

BACKGROUND AND AIM OF THE STUDY

With the changing age structure of the population, cardiothoracic surgeons must deal with an increasing number of patients suffering from degenerative valve disease. Septuagenarians with triple valve disease may be refused surgery due to a potentially high perioperative risk related to co-morbidities. The study aim was to elucidate the indications and compare outcome, with a focus on age-related mortality and morbidity.

METHODS

Between December 1996 and July 2010, a total of 90 consecutive patients (45 males, 45 females; mean age 68 +/- 9 years; logistic EuroSCORE 21 +/- 16%) underwent triple-valve surgery at Hannover Medical School. Of these patients, 70% had degenerative disease, 19% endocarditis, and 11% a rheumatic cause, while 24% underwent cardiac redo-surgery. For further analysis, the cohort was divided into two groups according to age: < or = 70 years (n=44) and >70 years (n=46). The follow up was performed according to current guidelines for reporting mortality and morbidity after cardiac valve interventions, including a quality of life assessment (Minnesota Living With Heart Failure Questionnaire; MLHFQ).

RESULTS

Mortality among the patients was 16%, 24%, and 26% at 30, 60, and 90 days, respectively. The one-year survival was 69% for the whole cohort, and no difference was seen between the age groups. Follow up (mean 46 months) was complete in 96% of all patients who survived at least three months (n=67). Valve-related morbidity was low in both groups, with predominantly a recurrence of tricuspid insufficiency. The MLHFQ score was similar in both groups.

CONCLUSION

Triple-valve surgery is associated with a high perioperative risk. However, the acceptance of elderly patients for this surgery is not associated with a higher mortality or valve-related morbidity. The patients' quality of life was acceptable during follow up, and not affected by age. Hence, the refusal of surgery should depend not on old age alone but rather on an individualized assessment of the patient.

Long-term results after aortic valve-sparing operation (David I)

OBJECTIVE

Aortic valve-sparing David procedure has gained broad acceptance. However, few long-term results have been published. We present our results.

METHODS

More than 450 David procedures have been performed in our institution so far. Of these, 126 patients were operated between July 1993 and December 2000. Median age was 57 (8-83) years and 46 (36.5%) were female. As many as 26 (20.6%) had Marfan syndrome, 21 (16.7%) had acute aortic dissection type A (AADA) and 67 (53.2%) had additional procedures.

RESULTS

There were six (4.8%) deaths in 30 post-operative period (POD), four of whom had AADA. In the follow-up, there were 32 (25.4%) late deaths, 11 (34.4%) of these were caused by cardiac or underlying disease or op-related. As many as 15 (11.9%) patients were re-operated; six (40%) were Marfan patients and two (13.3%) had early endocarditis. Follow-up echocardiography of 76 (60.3%) event-free patients showed valve insufficiency (AI)≤AI I° in 68 (89.5%) and grade II in 7 (9.2%) patients. Leaflet degeneration due to proposed leaflet contact with the straight Dacron graft was not observed. A total of 36 (47.4%) patients were in New York Heart Association (NYHA) class I, 33 (43.4%) in NYHA II, and five (6.6%) were in class III. During the entire follow-up of 790 patient-years, there was no stroke or major bleeding. Survival at 1, 5 and 10 years was 93%, 85% and 70%, respectively. Freedom from valve replacement at 1, 5 and 10 years was 96%, 91% and 87%, respectively.

CONCLUSIONS

Regardless of the underlying pathology, valve-sparing David I procedure has acceptable long-term results. Valve-related complications such as stroke or major bleeding is exceedingly low.

Rhesus monkey cardiosphere-derived cells for myocardial restoration

BACKGROUND AIMS

Cardiosphere-derived cells (CDC) have been proposed as a promising myocardial stem cell source for cardiac repair. They have been isolated from human, porcine and rodent cardiac biopsies. However, their usefulness for myocardial restoration remains controversial. We aimed to determine the survival, differentiation and functional effects of Rhesus monkey CDC (RhCDC) in a mouse model of myocardial infarction.

METHODS

RhCDC were isolated and characterized by flow cytometry and reverse transcriptase (RT)-polymerase chain reaction (PCR) and compared with human CDC. They were injected intramyocardially into severe combined immune deficiency (SCID) beige mice after ligature of the left anterior descending artery (LAD). Phosphate-buffered saline (PBS) served as placebo. Medium treatment alone was used to distinguish between cellular and non-cellular effects. Animals were divided into a non-infarcted control group (n = 7), infarct control groups (n = 24), medium-treated infarct groups (n = 35) and RhCDC-treated infarct groups (n = 33). Follow-up was either 1 or 4 weeks. LV function was assessed by pressure-volume loop analysis. Differentiation was analyzed by immunhistochemical profiling and RT-PCR.

RESULTS

Proliferating RhCDC grafts were detected after transplantation in an acute infarct model. RhCDC as well as medium treatment protected myocardium within the infarct area and improved LV function. RhCDC had a superior regenerative effect than medium alone.

CONCLUSIONS

For the first time, RhCDC have been used for the restoration of infarcted myocardium. RhCDC proliferated in vivo and positively influenced myocardial remodeling. This effect could be mimicked by treatment with unconditioned medium alone, emphasizing a non-cellular paracrine therapeutic mechanism. However, as a robust cardiac stem cell source, CDC might be useful to evoke prolonged paracrine actions in cardiac stem cell therapy.