Minimalinvasive chirurgische Verfahren zur kompletten Revaskularisation bei Mehrgefäßerkrankung werden zunehmend sowohl von PatientInnen als auch von ZuweiserInnen eingefordert. Wesentlich ist, dass die wichtigsten Therapieziele der Koronarchirurgie, konkret die komplette Revaskularisation, die konsequente arterielle Revaskularisation sowie die Minimierung aortaler Manipulation durch einen minimalinvasiven Zugang nicht kompromittiert werden. In einigen spezialisierten Zentren werden klinische Ergebnisse erreicht, welche mit denen der konventionellen Koronarchirurgie vergleichbar sind. Im vorliegenden Artikel geben wir einen Überblick über einige dieser Techniken, welche international mit Erfolg angewandt werden und welche sich in unserer Praxis bewährt haben. Unsere Technik basiert auf den von Paul Sergeant gelehrten Prinzipien der Off-Pump-Koronarchirurgie („off-pump coronary artery bypass grafting“, OPCAB). Die Plattform für unsere Technik zur minimalinvasiven Revaskularisation stellt MIDCAB dar („minimally invasive direct coronary artery bypass grafting“). Je nach Schweregrad der koronaren Herzkrankheit und abhängig von patientenspezifischen Komplexitätskriterien kommen verschiedene operative Techniken zur Anwendung (MIDCAB Plus sowie Multivessel-MIDCAB), welche hier überblicksmäßig präsentiert werden. Detailliertere Schritt-für-Schritt-Beschreibungen, ergänzt durch Zeichnungen, intraoperative Fotos und insbesondere Videodemonstrationen, finden sich in unserem Atlas Albert Angleitner – Minimally-Invasive Coronary Artery Bypass Surgery.

Minimally invasive surgical techniques to attain complete revascularization for multivessel coronary artery disease (minimally invasive cardiac surgery coronary artery bypass grafting, MICS-CABG) are increasingly demanded by patients and referring cardiologists. Importantly, a minimally invasive approach should not compromise the most important goals of CABG, specifically complete revascularization, consistent arterial revascularization and minimization of aortic manipulation. Some specialized centers achieve clinical outcomes that are comparable to conventional CABG. This article presents a review of several of these techniques that are successfully performed globally and have produced consistent results in our practice. Our technique is based on the principles of off-pump coronary artery bypass grafting (OPCAB) as taught by Paul Sergeant. The platform for our minimally invasive revascularization is minimally invasive direct coronary artery bypass grafting (MICAB). Depending on the severity of the coronary artery disease and several patient-specific complexity criteria, a variety of operative techniques are used (MIDCAB Plus and multivessel MIDCAB), which are outlined here. A more detailed presentation of these techniques, including step by step sequences, illustrations, intraoperative photographs and especially video demonstartions, can be found in our atlas Albert & Angleitner-Minimally invasive coronary artery bypass surgery.

MICS-CABGminimally-invasive cardiac surgical coronary artery bypass grafting OPCAB off-pump

Objectives: The Durable Mechanical Circulatory Support System After Extracorporeal Life Support registry is a multicenter registry of patients who were bridged from extracorporeal life support to a durable mechanical circulatory support system. Although numerous studies have highlighted the favorable outcomes after implantation of the HeartMate 3 (Abbott), the objective of our study is to examine the outcomes of patients who received HeartMate 3 support after extracorporeal life support. Methods: Data of patients undergoing HeartMate 3 implantation from January 2016 to April 2022 at 14 centers were collected and evaluated. Inclusion criteria were patients with extracorporeal life support before HeartMate 3 implantation. The outcome was reported and compared with patients receiving other types of pumps. Results: A total of 337 patients were bridged to durable mechanical circulatory support system after extracorporeal life support in the study period. Of those patients, 140 were supported with the HeartMate 3. The other types of pumps included 170 HeartWare HVADs (Medtronic) (86 % ), 14 HeartMate II devices (7 % ), and 13 (7 % ) other pumps (7 % ). Major postoperative complications included right heart failure requiring temporary right ventricular assist device in 60 patients (47 % ). Signi fi- cantly lower postoperative stroke (16 % vs 28 % , P = .01) and pump thrombosis (3 % vs 8 % , P = .02) rates were observed in the patients receiving the HeartMate 3. The 30-day, 1-year, and 3-year survivals in patients receiving the HeartMate 3 were 87 % , 73 % , and 65 % , respectively. Conclusions: In this critically ill patient population, the survivals of patients who were transitioned to the HeartMate 3 are deemed acceptable and superior to those observed when extracorporeal life support was bridged to other types of durable mechanical circulatory support systems. (J Thorac Cardiovasc Surg 2024;168:56978)

Objectives Durable mechanical circulatory support system (MCS) after (extra-corporeal Life Support (ECLS) registry is a multicenter registry of patients who were bridged from ECLS to durable MCS. While numerous studies have highlighted the favorable outcomes following HeartMate 3 (HM3) implantation, the objective of our study is to examine the outcomes of patients who received HeartMate 3 support after ECLS. Methods Data of patients undergoing HM 3 implantation from 01.2016 thru 04.2022 at 14 centers are collected and evaluated. Inclusion criteria were patients with ECLS support prior to HM3 implantation. The outcome was reported and compared to patients receiving other types of pumps. Results A total of 337 patients were bridged to durable MCS after ECLS in the study period. Out of those patients, 140 patients were supported with HM3. The other types of pumps included 170 HeartWare HVAD (86%), 14 HeartMate II (7%) and 13 (7%) other pumps (7%). Major postoperative complications included right heart failure requiring temporary right VAD in 60 patients (47%). A significantly lower postoperative stroke (16% vs. 28%, p= 0.01) and pump thrombosis (3% vs. 8 %, p= 0.02) rates were observed in the HM 3 patients. The 30 day, 1 year and 3 year survival in HM3 patients was 87%, 73% and 65% respectively. Conclusions In this critically ill patient population, the survival rates of patients who were transitioned to HeartMate 3 are deemed acceptable and superior to those observed when ECLS was bridged to other types of durable MCS.

OBJECTIVES: To achieve a beneficial impact on long-term outcome after coronary artery bypass grafting (CABG), the goal of the present study was the early identification of patients at risk of impaired postoperative health-related quality of life (HRQoL), particularly evaluating the significance of socio-demographic variables. METHODS: In this prospective, single-centre cohort study of patients having an isolated CABG (January 2004-December 2014), preoperative socio-demographic (preSOC) and preoperative medical variables as well as 6-month follow-up data including the Nottingham Health Profile were analysed in 3,237 patients. RESULTS: All preSOC (gender, age, marriage and employment) and follow-up (chest pain, dyspnoea) variables proved to have significant influence on HRQoL (P < 0.001), male patients below 60 years being particularly impaired. The effects of marriage and employment on HRQoL are modulated by age and gender. The significance of the predictors of reduced HRQoL differs between the 6 Nottingham Health Profile domains. Multivariable regression analyses revealed explained proportions of variance amounting to 7% for preSOC and 4% for preoperative medical variables. CONCLUSIONS: The identification of patients at risk of impaired postoperative HRQoL is decisive for providing additional support. This study reveals that the assessment of 4 preoperative socio-demographic characteristics (age, gender, marriage, employment) is more predictive of HRQoL after CABG than are multiple medical variables.

Central MessageA single-incision, minimally invasive LVAD implantation with outflow graft anastomosed to the ascending aorta is feasible. Prior experience with less-invasive procedures is inevitable. A single-incision, minimally invasive LVAD implantation with outflow graft anastomosed to the ascending aorta is feasible. Prior experience with less-invasive procedures is inevitable. Less-invasive or minimally invasive implant strategies for left ventricular assist devices (LVADs) usually involve minimizing or completely avoiding sternal trauma, avoiding heart luxation while simultaneously leaving the major part of pericardium intact. The current literature supports the advantages of less-invasive LVAD implantations that include less re-exploration for bleeding, blood product utilization, and postoperative right ventricle failure as well as shorter length of hospital stay.1Al-Naamani A. Fahr F. Khan A. Bireta C. Nozdrzykowski M. Feder S. et al.Minimally invasive ventricular assist device implantation.J Thorac Dis. 2021; 13: 2010-2017Crossref PubMed Scopus (10) Google Scholar, 2Jawad K. Sipahi F. Koziarz A. Huhn S. Kalampokas N. Albert A. et al.Less-invasive ventricular assist device implantation: a multicenter study.J Thorac Cardiovasc Surg. 2022; 164: 1910-1918.e4Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 3Potapov E. Loforte A. Pappalardo F. Morshuis M. Schibilsky D. Zimpfer D. et al.Impact of a surgical approach for implantation of durable left ventricular assist devices in patients on extracorporeal life support.J Card Surg. 2021; 36: 1344-1351Crossref PubMed Scopus (8) Google Scholar, 4Saeed D. Muslem R. Rasheed M. Caliskan K. Kalampokas N. Sipahi F. et al.Less invasive surgical implant strategy and right heart failure after LVAD implantation.J Heart Lung Transplant. 2021; 40: 289-297Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Most surgeons use a left minithoracotomy for implantation of the pump combined with a hemisternotomy or right-sided minithoracotomy to attach the outflow graft to the ascending aorta.1Al-Naamani A. Fahr F. Khan A. Bireta C. Nozdrzykowski M. Feder S. et al.Minimally invasive ventricular assist device implantation.J Thorac Dis. 2021; 13: 2010-2017Crossref PubMed Scopus (10) Google Scholar,5Schmitto J.D. Mariani S. Abicht T.O. Couper G.S. Danter M.R. Itoh A. et al.Expert consensus paper: lateral thoracotomy for ccentrifugal ventricular assist device implant.Ann Thorac Surg. 2021; 112: 1687-1697Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar, 6Popov A.F. Mohite P.N. Sabashnikov A. Weymann A. Patil N.P. Sáez D.G. et al.Minimally invasive HeartWare LVAD implantation through single left thoracotomy.J Artif Organs. 2015; 18: 170-172Crossref PubMed Scopus (12) Google Scholar, 7Saeed D. Sixt S. Albert A. Lichtenberg A. Minimally invasive off-pump implantation of HeartMate 3 left ventricular assist device.J Thorac Cardiovasc Surg. 2016; 152: 1446-1447Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar In this report, we introduce a novel technique for LVAD implantation whereby the pump implantation is performed through a single minithoracotomy incision. We call this procedure the minimally invasive direct left ventricular assist device (MIDVAD) implantation (see Video 1). The advantage of this technique is that antegrade blood flow in the ascending aorta is maintained and the sternum remains intact without additional skin incision for the outflow graft anastomosis. The MIDVAD technique is only feasible if no additional procedure is necessary and the patient has no history of previous cardiac procedures. There are several other procedure-related caveats that require close attention. For instance, similar to other minimally invasive procedures, this technique is more challenging in patients with higher body mass index. In addition, single lung ventilation is necessary for this procedure and may be a limiting factor in patients with compromised lung function. Finally, preoperative computed tomography scanning is inevitable to exclude calcification of the ascending aorta and subsequent stroke risk. A total of 3 50- to 66-year-old patients in New York Heart Association functional class III and IV and Interagency Registry for Mechanically Assisted Circulatory Support class 4 were supported with the HeartMate 3 pump (Abbott) using this technique. The patients were free from procedure-related adverse events. The institutional review board at Witten/Herdecke University approved this study (approval No. S-164/2022; September 9, 2022). Written informed consent for the publication of the study data was obtained from all patients. The patients were put on cardiopulmonary bypass via the femoral vessels (or the right axillary artery if the femoral artery was calcified) during the preoperative computed tomography scan. Single lung ventilation was used and the right lung was continuously ventilated. An anterolateral left-sided minithoracotomy was performed through the fifth or sixth intercostal space with an incision length of 7 to 12 cm. An endoscopy was set through the fourth intercostal space and the chest cavity was flooded with carbon dioxide. The pericardium was incised longitudinally from the left ventricular apex to the aorta. Afterward, a minimally invasive direct coronary artery bypass retractor was used and the ascending aorta was exposed to insert a vent catheter in the distal ascending aorta for de-airing. The technique for exposing the aorta is based on the Ottawa procedure, which is known from minimally invasive cardiac surgery coronary artery bypass (MICs-CABG)8Chan V. Lapierre H. Sohmer B. Mesana T.G. Ruel M. Handsewn proximal anastomoses onto the ascending aorta through a small left thoracotomy during minimally invasive multivessel coronary artery bypass grafting: a stepwise approach to safety and reproducibility.Semin Thorac Cardiovasc Surg. 2012; 24: 79-83Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar: the ventilation pressure and positive end-expiratory pressure to the right lung was increased (to move the mediastinum to the left); serial traction sutures on the right side of the pericardium were placed (to pull up the aorta); wet gauze was applied to the right-lateral aspect of the aorta (displacing it medially); a coronary tissue stabilizer was used (to lightly press the pulmonary artery dorsally and medially), if necessary; and an additional, upper intercostal space was opened through the same left sided minithoracotomy to facilitate access to the ascending aorta. Next, the apex was exposed and the HeartMate 3 device was inserted into the ventricle as described previously.1Al-Naamani A. Fahr F. Khan A. Bireta C. Nozdrzykowski M. Feder S. et al.Minimally invasive ventricular assist device implantation.J Thorac Dis. 2021; 13: 2010-2017Crossref PubMed Scopus (10) Google Scholar Great care was given to properly de-air the pump through the graft and aorta. The driveline was tunneled in the usual manner. The outflow graft was sized appropriately to avoid kinking and right ventricle compression and was tunneled within the pericardium. Partial aortic clamping was placed and the outflow graft was attached to the anterior part of the proximal ascending aorta. Cardiopulmonary bypass was weaned and the pump was started. Finally, the chest and groin cannulation sites were closed. Figure 1 shows the 3-dimensional computed tomography scan of the pump position and the course of the outflow graft. Major issues include bleeding from the aortic anastomosis site and the management of secondary right heart failure. In the case of bleeding, a direct view of the suture line is mandatory. A bailout sternotomy may be necessary to control bleeding complications. This was not necessary in our cases. In case of secondary right heart failure requiring mechanical support, we advocate for less-invasive percutaneous approaches (eg, using ProtekDuo cannulae [LivaNova]). Alternatively, a graft is attached to the pulmonary artery (as outflow cannula) and exteriorized using the same incision and the venous cannula in the groin used as inflow for the right VAD. Our experience with this technique of right VAD implantation has been described before.9Saeed D. Maxhera B. Kamiya H. Lichtenberg A. Albert A. Alternative right ventricular assist device implantation technique for patients with perioperative right ventricular failure.J Thorac Cardiovasc Surg. 2015; 149: 927-932Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar To our knowledge, these are the first patients receiving HeartMate 3 implantation and outflow graft anastomoses to the proximal ascending aorta through a single minithoracotomy incision (Figure 2). Apart from minimization of the surgical trauma (a potential advantage for future surgeries), the MIDVAD approach offers the advantage of keeping the sternum intact while physiological antegrade blood flow in the ascending aorta is maintained. The technique to perform a handsewn proximal anastomosis onto the ascending aorta through a small left thoracotomy is well known in MICs-CABG procedures.8Chan V. Lapierre H. Sohmer B. Mesana T.G. Ruel M. Handsewn proximal anastomoses onto the ascending aorta through a small left thoracotomy during minimally invasive multivessel coronary artery bypass grafting: a stepwise approach to safety and reproducibility.Semin Thorac Cardiovasc Surg. 2012; 24: 79-83Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar By applying this MICs-CABG technique to the known less-invasive LVAD implantation technique, the safety and feasibility are maintained. As previously described, optimal patient selection and prior experience with less-invasive LVAD implantation is mandatory to achieve excellent results. Further studies are necessary to evaluate the possible benefits and the applicability of this technique in a broader patient population. The authors thank Dr Konstantinos Smiris for his assistance during preparation of the video. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIzN2RiN2QxNjA4YzEyZjEwMmNhOWFkNjBiOTI1MTJiZSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk1MDc1NjAyfQ.bIhXNpGyo650qFp7tZozvWOGAKTHZF26yOkuQPk0-OqM-RkJdORKifu__Q5IW654gu_skhIA5NTSvJipsG2PEm0eC0rEVkfqKAFYhZIT2a9UsZCxZCAbpI7c_28KeX58Gs1PTp7qS2BVHjh_tsfj5poA96VqoD60ggvPQe6NJo9-8aMbVSrgP2ngUDH_jIYoaNU7e29aq3GLZfs2SX_2-q19LEx_qIWMLslN-D9RAK8PDBwYw02YQ8JMWMUw9Ta6MVfb4fg_FPviPDAk_5KtOn-2yMgmLxbnVVE0OvNBGo8slJAkDreh3bpbGYAVpWUvhJjUJWkPeiiGUMBjMJnmUQ Download .mp4 (152.18 MB) Help with .mp4 files Video 1The video displays the MIDVAD procedure, including the placement of the HeartMate 3 pump (Abbott) into the left apex and the attachment of the outflow graft to the proximal ascending aorta. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00061-5/fulltext. Download .jpg (.25 MB) Help with files Video 1The video displays the MIDVAD procedure, including the placement of the HeartMate 3 pump (Abbott) into the left apex and the attachment of the outflow graft to the proximal ascending aorta. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00061-5/fulltext.

Background: Our group recently published the largest series of patients who were supported with durable mechanical circulatory support systems (MCS) after extra corporeal life support (ECLS). Based on those data (up to June 2018), a formula was generated that predict 1 year survival. However, no validation studies have been performed yet. The aim of this study was to validate the previously described survival predictor.

Background: Coronary artery bypass grafting (CABG) aims at prevention of myocardial infarction, relief from angina and dyspnea, and thereby improvement of health-related quality of life (HRQoL). To achieve a beneficial impact especially on the long-term outcome, it is crucial to early identify CABG patients at risk of impaired HRQoL. The present study was designed to determine preoperative risk factors for reduced postoperative HRQoL in a large cohort of consecutive isolated CABG patients. In particular, the significance of socio-demographic variables in comparison to medical characteristics was evaluated.

Aims Extracorporeal life support (ECLS) represents a popular treatment option for therapy-refractory circulatory failure and substantially increases survival. However, comprehensive follow-up (FU) data beyond short-term survival are mostly lacking. Here, we analyse functional recovery and quality of life of longer-term survivors. Methods and results Between 2011 and 2016, a total of n = 246 consecutive patients were treated with ECLS for therapy-refractory circulatory failure in our centre. Out of those, 99 patients (40.2%) survived the first 30 days and were retrospectively analysed. Fifty-eight patients (23.6%) were still alive after a mean FU of 32.4 +/- 16.8 months. All surviving patients were invited to a prospective, comprehensive clinical FU assessment, which was completed by 39 patients (67.2% of survivors). Despite high incidence of early functional impairments, FU assessment revealed a high degree of organ and functional recovery with more than 70% of patients presenting with New York Heart Association class <= II, 100% free of haemodialysis, 100% free of moderate or severe neurological disability, 71.8% free of moderate or severe depression, and 84.4% of patients reporting to be caring for themselves without need for assistance. Conclusions Patients surviving the first 30 days of ECLS therapy for circulatory failure without severe adverse events have a quite favourable outcome in terms of subsequent survival as well as functional recovery, showing the potential of ECLS therapy for patients to recover. Patients can recover even after long periods of mechanically support and regain physical and mental health to participate in their former daily life and work.

Management of patients with acute type A aortic dissection (ATAAD) presenting with cerebral malperfusion due to carotid artery obstruction is still a major challenge and often associated with poor prognosis despite successful surgical aortic repair, due to prolonged cerebral perfusion deficit. Here, we present the first report regarding successful percutaneous recanalization of an internal carotid artery occlusion in the setting of an ATAAD before open surgical aortic repair with excellent clinical outcome after three year follow-up, including almost full neurological recovery.

Objectives: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may be cannulated using either central (cannulation of aorta) or peripheral (cannulation of femoral or axillary artery) access. The ideal cannulation approach for postcardiotomy cardiogenic shock (PCS) is still unknown. The aim of this study is to compare the outcome of patients with PCS who were supported with central vs. peripheral cannulation. Methods: This is a single-center retrospective data analysis including all VA-ECMO implantations for PCS from January 2011 to December 2017. The central and peripheral approaches were compared in terms of patient characteristics, intensive care unit (ICU) stay, hospitalization length, adverse event rates, and overall survival. Results: Eighty-six patients met the inclusion criteria. Twenty-eight patients (33%) were cannulated using the central approach, and 58 patients (67%) were cannulated using the peripheral approach. Forty-three patients (50%) received VA-ECMO in the operating room and 43 patients (50%) received VA-ECMO in the ICU. Central VA-ECMO group had higher EuroSCORE II ( p = 0.007), longer cross-clamp time ( p = 0.054), higher rate of open chest after the procedure ( p < 0.001), and higher mortality rate ( p = 0.02). After propensity score matching, 20 patients in each group were reanalyzed. In the matched groups, no statistically significant differences were observed in the baseline characteristics between the two groups except for a higher rate of open chests in the central ECMO group ( p = 0.02). However, no significant differences were observed in the outcome and complications between the groups. Conclusions: This study showed that in postcardiotomy patients requiring VA-ECMO support, similar complication rates and outcome were observed regardless of the cannulation strategy.

Background Femoral cannulation for extracorporeal circulation (ECC) is a standard procedure for minimally invasive cardiac surgery (MICS) of the atrio-ventricular valves. Vascular pathologies may cause serious complications. Preoperative computed tomography-angiography (CT-A) of the aorta, axillary and iliac arteries was implemented at our department. Methods Between July 2017 and December 2018 all MICS were retrospectively reviewed ( n = 143), and divided into 3 groups. Results In patients without CT ( n = 45, 31.5%) ECC was applied via femoral arteries (91.1% right, 8.9% left). Vascular related complications (dissection, stroke, coronary and visceral ischemia, related in-hospital death) occurred in 3 patients (6.7%). In patients with non-contrast CT ( n = 35, 24.5%) only femoral cannulation was applied (94.3% right) with complications in 4 patients (11.4%). CT-angiography ( n = 63, 44.1%) identified 12 patients (19.0%) with vulnerable plaques, 7 patients (11.1%) with kinking of iliac vessels, 41 patients (65.1%) with multiple calcified plaques and 5 patients (7.9%) with small femoral artery diameter (d ≤ 6 mm). In 7 patients (11.1%) pathologic findings led to alternative cannulation via right axillary artery, additional 4 patients (6.3%) were cannulated via left femoral artery. Only 2 patients (3.2%) suffered from complications. Conclusions CT-A identifies vascular pathologies otherwise undetectable in routine preoperative preparation. A standardized imaging protocol may help to customize the operative strategy.

Calcific aortic valve disease is the most common valvular heart disease in industrialized countries. Pulsatile pressure, sheer and bending stress promote initiation and progression of aortic valve degeneration. The aim of this work is to establish an ex vivo model to study the therein involved processes. Ovine aortic roots bearing aortic valve leaflets were cultivated in an elaborated bioreactor system with pulsatile flow, physiological temperature, and controlled pressure and pH values. Standard and pro-degenerative treatment were studied regarding the impact on morphology, calcification, and gene expression. In particular, differentiation, matrix remodeling, and degeneration were also compared to a static cultivation model. Bioreactor cultivation led to shrinking and thickening of the valve leaflets compared to native leaflets while gross morphology and the presence of valvular interstitial cells were preserved. Degenerative conditions induced considerable leaflet calcification. In comparison to static cultivation, collagen gene expression was stable under bioreactor cultivation, whereas expression of hypoxia-related markers was increased. Osteopontin gene expression was differentially altered compared to protein expression, indicating an enhanced protein turnover. The present ex vivo model is an adequate and effective system to analyze aortic valve degeneration under controlled physiological conditions without the need of additional growth factors.

Aim: The aim of this study was to evaluate the prognostic value of osteopontin (OPN) as a marker for left ventricular (LV) hypertrophy and its reversibility after surgical aortic valve replacement (SAVR). Patients & methods: Echocardiographic data and OPN plasma levels of 149 consecutive patients undergoing SAVR were obtained preoperatively and 3 months postoperatively. OPN was measured by Quantikine Human OPN immunoassay. Results: There was a significant correlation between higher OPN plasma levels and lower LV-mass regression. In patients receiving SAVR combined with coronary artery bypass grafting, high OPN plasma levels were also an indicator for eccentric hypertrophy phenotype. Conclusion: OPN may be a useful indicator for LV hypertrophy phenotype and could have a prognostic value to estimate LV-mass regression after SAVR.

In this matched group of patients, LIS approach seems to result in lower postoperative morbidities (lower reexploration rate for bleeding and severe RV failure) and shorter hospital stay. Nevertheless, the survival remains similar between the groups.

OBJECTIVE:The present study aimed to determine whether underlying disease, performed surgery, and dose of tranexamic acid influence fibrinolysis measured with D-dimer levels.DESIGN:Retrospective analysis.SETTING:Single institution (Department of Cardiac Surgery and Section of Clinical Hemostaseology at the Düsseldorf University Hospital).PARTICIPANTS:The study comprised 3,152 adult patients undergoing elective cardiac surgery between February 2013 and October 2016.INTERVENTIONS:Two doses of tranexamic acid during surgery were administered.MEASUREMENTS AND MAIN RESULTS:D-dimer levels were analyzed at the start of surgery and before protamine administration. D-dimer levels at the start of surgery were compared according to disease. Intraoperative D-dimer development was analyzed according to the type of surgery and within 2 cohorts with different tranexamic acid doses. Interindividual variability was pronounced for D-dimer levels at the start of surgery, with significant differences among patients with coronary artery disease, valve disease, and aortic disease and patients undergoing heart transplantation compared with patients receiving a left ventricular assist device (p < 0.01). Aortic dissection, endocarditis, and extracorporeal life support were associated with higher D-dimer levels (p ≤ 0.01). With tranexamic acid at a fixed dose, intraoperative D-dimer levels decreased in on-pump and off-pump coronary bypass surgery, valve surgery, and left ventricular assist device surgery (p ≤ 0.02), but levels increased in aortic surgery and heart transplantations (p < 0.01). A decrease or increase in D-dimer levels during surgery was influenced significantly by a higher or lower tranexamic acid dose (p ≤ 0.01).CONCLUSIONS:D-dimer testing allows for the assessment of individual fibrinolytic activity in cardiac surgery, which is influenced by disease type, surgery type, and dose of tranexamic acid. The assessment of the fibrinolytic status may have the potential to facilitate dose-adjusted antifibrinolytic therapy in the future.