Objectives Workforce shortages in cardiac surgery (CS) are increasing despite high initial interest among young physicians. Attrition remains poorly understood and is often attributed to individual limitations rather than systemic factors. This study aimed to identify determinants of attrition, characterize subsequent career pathways, and define targets for improving retention. Methods A German nationwide, anonymous, questionnaire-based survey (47 items) was conducted between July 2024 and January 2026 among physicians with previous employment in German CS departments. Descriptive statistics and subgroup analyses were performed. Results Seventy-five participants were included. Initial motivation for pursuing cardiac surgery was high and mainly driven by interest in the specialty’s technical and intellectual complexity. However, satisfaction with key aspects of training was low, particularly regarding surgical training (23.3%, 17/73), scientific support (24.7%, 18/73), and professional mentorship and career development (28.8%, 21/73). The most frequently reported reasons for leaving were poor work–life balance (74.2%, 46/62), dissatisfaction with workplace culture (67.7%, 42/62), limited career opportunities (66.1%, 41/62), and lack of appreciation (62.9%, 39/62). Attrition occurred across all career stages, including board-certified surgeons and senior staff. Despite leaving the specialty, most participants were satisfied with their decision (95.1%, 58/61), while only 11.7% (7/60) considered returning to cardiac surgery. Conclusion This exploratory survey suggests that attrition from cardiac surgery is frequently associated with dissatisfaction regarding work-life balance, workplace culture, career perspectives, and training conditions rather than with self-perceived individual limitations. While causal relationships cannot be established, the findings highlight potentially modifiable organizational factors that may represent targets for future retention strategies in cardiac surgery.

OBJECTIVES:Microaxial flow pumps (mAFP) effectively bridge patients with cardiogenic shock to durable left ventricular assist device (dLVAD) implantation. The partial-support mAFPs provide only up to 3.5 L/min, which might be insufficient for an effective circulatory support and preconditioning for a dLVAD implantation. Alternatively, patients with refractory shock on partial support may benefit from an escalation to a full-support mAFP. METHODS:A retrospective analysis of 130 patients was performed across 17 European cardiac centres who underwent dLVAD implantation following mAFP with or without venoarterial extracorporeal life support (VA-ECLS) between February 2015 and August 2022. Ninety-two patients (70.8%) were bridged on partial-support mAFP, while 38 patients (29.2%) underwent an escalation to full-support mAFP. RESULTS:Median support duration was significantly longer in the escalation group (7 days [4, 11] vs 12 days [9, 21], P < .001). Patients in the escalation group were more likely to be weaned from VA-ECLS before dLVAD implantation, 10 (71.4%) vs 6 (11.3%), P < .001. Thirty-day survival was similar between the escalation and no-escalation groups, 89.5% vs 84.8% (IPTW-weighted OR, 1.00 [95% CI, 0.46-2.22], P = .992). Estimated 1-year survival was higher in the escalation group: 84.0% [95% CI, 73.0-96.6] vs 63.7% [95% CI, 54.3-74.6], HR 0.41 [95% CI, 0.17-0.99], P = .048. Patients with a combination of partial-support mAFP and VA-ECLS had a higher mortality risk than all other patients, HR 2.06 [95% CI, 1.16-3.36], P = .013. CONCLUSIONS:In patients with partial-support mAFP and concomitant VA-ECLS, an escalation to a full-support mAFP may translate to improved survival and should be considered to facilitate VA-ECLS weaning.

BACKGROUND AND AIMS:Aortic stenosis may be managed differently in women and men, but evidence remains limited. Sex-specific characteristics and outcomes of low- to intermediate-risk patients assigned to transcatheter aortic valve implantation (TAVI) or surgical aortic valve replacement (SAVR) from the DEDICATE-DZHK6 trial are described. METHODS:The DEDICATE-DZHK6 trial demonstrated non-inferiority for the primary outcome of all-cause death or stroke at 1 year. Sex-specific effects were evaluated in this predefined descriptive subgroup analysis. RESULTS:A total of 1394 patients (43.3% women) were included. Women were older (women: 74.8 ± 4.6 years vs men: 74.2 ± 4.2 years, P = .020) and at higher operative risk [median Society of Thoracic Surgeons risk score 2.1% (1.5-2.7) vs 1.5% (1.0-2.2), P < .001]. All-cause death or stroke at 1 year was 5.2% in the TAVI vs 11.5% in the SAVR group [hazard ratio (HR) 0.46; 95% confidence interval (CI) 0.25-0.82] in women and 5.4% vs 9.0% (HR 0.61; 95% CI 0.35-1.03) in men. At 1 year after TAVI vs SAVR, all-cause death occurred in 2.6% vs 6.7% (HR 0.41; 95% CI 0.17-0.90) in women and 2.6% vs 5.9% (HR 0.44; 95% CI 0.20-0.88) in men. Stroke occurred in 2.6% vs 6.2% (HR 0.43; 95% CI 0.18-0.93) in women and 3.1% vs 3.6% (HR 0.89; 95% CI 0.41-1.90) in men. CONCLUSIONS:Among patients with severe aortic stenosis at low to intermediate risk, TAVI was non-inferior to SAVR for the primary outcome in women and men with lower event rates in patients assigned to TAVI. Women were at particular risk for early complications irrespective of the assigned treatment and at increased stroke risk after SAVR.

BACKGROUND:Biventricular failure or right ventricular failure (RVF) after continuous-flow left ventricular assist device (cf-LVAD) implantation is associated with high mortality. Durable right ventricular assist device (RVAD) options are limited, particularly for patients with critical cardiogenic shock or late-onset RVF. Use of right-sided cf-LVAD is costly, complex, and off-label. This study explores a hybrid VAD approach, combining a cf-LVAD and a Berlin Heart EXCOR pulsatile RVAD. METHODS:This multicenter retrospective analysis included patients who received a cf-LVAD with an EXCOR RVAD at six centers in Germany between December 2017 and January 2024. Nineteen patients were analyzed. Baseline demographics, implantation strategy, duration of support, survival, and end-organ function were assessed. RESULTS:Among the 19 patients, 73.7% were male, with a median age of 52 years (IQR 30.5-59.5). Seventeen (89.5%) patients initially presented in INTERMACS level 1 and 14 patients underwent stabilization with temporary mechanical circulatory support before durable VAD implantation resulting in a shift to INTERMACS level 3. Simultaneous LVAD and RVAD implantation occurred in 13 (68.4%) patients. Median hybrid support duration was 112 days (range 9 - 1363 days). One-year mortality was 21.1% overall and 14.3% in patients with simultaneous BIVAD implantation. Improved renal and hepatic function was observed, particularly in patients with simultaneous biventricular support. CONCLUSION:Hybrid support using a cf-LVAD with an EXCOR RVAD is a feasible and effective strategy for patients with biventricular failure. This approach demonstrated favorable survival, especially with simultaneous implantation, and was associated with improved end-organ function.

BACKGROUND:Atrial arrhythmias relevantly contribute to global morbidity and death and have been extensively studied in experimental models. However, electrophysiological disparities between animal models and humans often hinder the translation of experimental findings. This study aims to systematically characterize species-specific atrial electrophysiology to improve translation. METHODS:Atrial tissue samples were obtained from patients undergoing open heart surgery and from mice, rats, pigs, and horses, and were characterized at the cellular electrophysiological and transcriptomic level using uniform protocols. To assess the correlation of functional and transcriptomic features, action potentials were simulated from ion channel expression profiles using in silico models. RESULTS:Porcine atrial cardiomyocytes closely resembled human cells in depolarization characteristics, whereas rodents exhibited marked differences. Human atrial action potentials showed pronounced early repolarization, which was not reproduced in other species and corresponded to a greater contribution of the IKur gene group. Late repolarization, reflected by action potential duration at 90% repolarization, scaled with species and cardiomyocyte size, with humans ranging between rodents and pigs. Sex-specific differences in repolarization observed in humans were represented in pigs but not in rodents. Chamber-specific differences between left and right atrial cardiomyocytes were reflected in in silico simulations on the basis of ion channel expression. CONCLUSIONS:This study provides a reference for species-specific atrial action potential characteristics, linking functional properties to transcriptomic ion channel expression. It further demonstrates that relative changes in action potential parameters can be inferred from transcriptomic data using in silico simulations. These findings support more accurate interpretation and translation of animal experimental data to human atrial electrophysiology.

Heart failure (HF) remains a progressive condition even with optimal medical therapy, often requiring advanced interventions like left ventricular assist devices (LVAD). Recent advancements in HF treatment, including sodium-glucose co-transporter 2 inhibitors (SGLT2i), have demonstrated benefits such as reduced mortality, symptom improvement, and renal protection. Their effects in LVAD patients remain unexplored. This study aims to evaluate the safety and therapeutic potential of SGLT2i in LVAD recipients, addressing a critical gap in current knowledge. A retrospective analysis of 176 consecutive patients who underwent LVAD implantation at two major academic centers in Germany (2018–2023) was conducted. In 139 LVAD patients (58 SGLT2i vs. 81 controls), we compared clinical and laboratory parameters at 6 and 12 months. In an additional group of 37 SGLT2i naïve patients who were already established on LVAD support the clinical course was compared to the pre-SGLT2i era. Renal function and cardiac biomarkers were not negatively affected during the first year of SGLT2i use. Complication rates ( eg , infections, hypovolemic events, acute kidney injury) were comparable to both the control group and pre-SGLT2i era. Sodium-glucose co-transporter 2 inhibitors as part of contemporary HF medication appear to be safe for LVAD patients. Further research and longer follow-up periods are necessary to draw robust conclusions on cardiovascular and renal outcomes.

Background:Patients on heart transplant waiting lists are often on antithrombotic (AT) drugs. Emergency orthotopic heart transplantation (OHT) when performed on such patients without optimal washout periods increases the risk of severe perioperative bleeding. Intraoperative AT removal by hemoadsorption may mitigate excess bleeding risks. Methods:The international Safe and Timely Antithrombotic Removal (STAR) registry captures real-world outcomes (ClinicalTrials.gov# NCT05077124). Included patients were on ticagrelor or direct-acting oral anticoagulants (DOACs) undergoing emergent OHT. Hemoadsorption was integrated into the cardiopulmonary bypass (CPB) circuit. Bleeding was assessed with the universal definition of perioperative bleeding (UDPB) and volume of chest tube drainage (CTD). Results:Seven patients were included (3 ticagrelor, 2 apixaban, 2 dabigatran; mean age 39.1 ± 11.1 years; 4 females). Mean time from the last AT dose to surgery was 29.4 ± 13.4 hours. Mean CPB duration was 206.0 ± 56.9 minutes with a mean device flow of 340 ± 126 ml. There were no massive bleeding events (UDPB 4), surgical revisions to control bleeding, or deaths within 30 days. Severe bleeding (UDPB 3) occurred in 1/7 (14.3%). Mean 12-hour and 24-hour CTD were 385.7 ± 263.4 m and 586.1 ± 315.0 ml, respectively. No device-related adverse events were reported. Conclusions:This case series from the ongoing STAR registry shows that intraoperative AT removal is simple and potentially effective in minimizing serious perioperative bleeding in patients on ticagrelor or DOACs undergoing OHT. Prospective, controlled studies in larger cohorts are needed to validate these promising observations.

To analyze dalbavancin’s potential for long-term suppressive therapy in patients with infected ventricular assist devices (VAD), the VAD register of Heidelberg University Hospital was searched for patients who received dalbavancin for long-term suppression therapy. Clinical data, laboratory, and microbiological results were extracted. Healthcare utilization was analyzed by number of hospitalizations before and during dalbavancin therapy with a generalized linear mixed model. Drug safety was investigated with regard to liver and renal function, and thrombocyte count. Thirteen patients were included in the study; receiving a regimen of 1500 mg dalbavancin at day 1 and day 8 with repetition of the cycle at day 42. The mean follow-up time was 254 days (IQR 252). Eight patients were treated for driveline infection and five patients for driveline and blood stream infection, all of them caused by Staphylococcus aureus. The majority of patients (n = 11/13) underwent surgical wound debridement and intravenous antibiotic therapy before start of dalbavancin. Under dalbavancin therapy, no blood stream infection was observed and significantly fewer hospitalizations occurred with an odds ratio of 0.27 (p < 0.001). In four patients, elevations of liver transaminases were detected and led to discontinuation of dalbavancin therapy in one patient.

Objectives Severe perioperative bleeding occurs in over 30 % of patients on ticagrelor undergoing isolated coronary artery bypass grafting (i-CABG) before completing the recommended 3-day washout. Intraoperative ticagrelor removal with a polymer bead hemoadsorption device is an approved therapy that may reduce perioperative bleeding. Methods The current analysis from the international Safe and Timely Antithrombotic Removal (STAR) registry reports outcomes with intraoperative hemoadsorption in patients on ticagrelor undergoing i-CABG before completing the recommended washout. Bleeding was assessed by the Universal Definition of Perioperative Bleeding (UDPB) definition. Results 102 patients (63.8 ± 10.1 years, 81.2 % male) underwent i-CABG at mean time from last dose (TLD) of 22.8 ± 14.6 h. Groups were created based on TLD to CABG: Group-1 (G1): <24 h (n = 61; TLD 12.6 ± 6.5 h); Group-2 (G2): 24-72 h (n = 41; 37.2 ± 10.1 h). G1 was higher risk than G2 based on EuroSCORE-II (median: 4.2 % vs. 1.7 %, p = 0.006) and emergency indication (66.1 % vs. 12.2 %, p < 0.001). Operation and cardiopulmonary bypass durations were similar (G1: 4.3 ± 1.5 h and 94.9 ± 37.1 min vs. G2: 4.4 ± 1 h and 94.7 ± 36.1 min, p = ns). Severe bleeding (UDPB≥3) and re-operations for bleeding were more frequent in G1 vs. G2 (14.8 % vs. 2.4 %, p = 0.047, and 8.2 % vs. 0 %, p = 0.08, respectively). Any transfusion of red blood cells or platelets was also more frequent in G1 vs. G2 (45.9 % vs. 26.8 %, p = 0.05 and 59.0 % vs. 34.1 %, p = 0.014, respectively). Conclusions Intraoperative ticagrelor removal may help reduce ticagrelor-related bleeding in patients undergoing i-CABG before completing the 3-day washout. High risk emergency procedures within the first 24 h of last ticagrelor dose have an increased bleeding risk. Clinical trial registry number ClinicalTrials.gov: NCT05077124.

Patients with acute decompensated advanced heart failure requiring left ventricular assist device (LVAD) implantation often experience progressive cardiac function deterioration, negatively impacting surgical outcomes. This study aimed to assess the efficacy of different microaxial flow pump (mAFP) support devices (Impella®) in achieving optimal left ventricular unloading for preconditioning and facilitating definitive treatment in this high-risk patient cohort. A retrospective analysis was conducted across 19 high-volume European centres. The study population included patients transitioning from temporary to durable circulatory support over a 7.5-year period, with a median follow-up of 1 year. Patients were categorized based on mAFP support capacity: those receiving high-flow support (>5 L/min, '5+') and those with lower-flow support (3.5 L/min, 'CP'). Patients who were initially treated with CP but subsequently upgraded to 5+ support were classified in the 5+ group. Demographic and clinical characteristics, mobilization, right heart function, and organ dysfunction outcomes were analysed. A total of 339 patients received preoperative mAFP support prior to LVAD implantation. The 5+ group comprised 247 patients (73%), including 38 patients who were upgraded from CP, while the CP group included 92 patients (27%). Baseline demographic and clinical characteristics were comparable between groups, except for mobilization status, which showed significant differences (P < 0.001). Patients in the 5+ group achieved higher rates of full and partial mobilization compared to the CP group. Extracorporeal life support (ECLS) was more frequently required in the CP group than in the 5+ group (40.5% vs. 33.8%; P < 0.001). Additionally, right ventricular assist device (RVAD) implantation was significantly more common in the CP group (29.2% vs. 18.2%; P = 0.026). Patients in the 5+ group demonstrated greater reductions in both vasoactive inotropic scores (P = 0.006) and inotropic scores (P = 0.008). Furthermore, liver dysfunction (P = 0.016), renal failure (P = 0.041), and the need for dialysis (P = 0.013) were significantly more prevalent in the CP group. There were no significant differences between the two groups in terms of LVAD operative duration (P = 0.637) or cardiopulmonary bypass time (P = 0.408). High-flow mAFP devices (+5) provided superior haemodynamic support, enhanced left ventricular unloading, and reduced dependence on catecholamines compared to lower-flow CP devices. These improvements were associated with lower rates of right ventricular failure, renal dysfunction, and liver injury. However, no statistically significant difference was observed between mAFP groups regarding 30-day mortality rates.

Background: A detailed understanding of cardiac anatomy and physiology is crucial in cardiovascular medicine. However, traditional learning methods often fall short in addressing this complexity. Augmented reality (AR) offers a promising tool to enhance comprehension. To assess its potential integration into the Heidelberger Curriculum Medicinale (HeiCuMed), we conducted a needs assessment among medical students and lecturers at Heidelberg University Medical School. Methods: Our survey aimed to evaluate the perceived benefits of AR-based learning compared to conventional methods and to gather expectations regarding an AR course in cardiovascular medicine. Using LimeSurvey, we developed a questionnaire to assess participants’ prior AR experience, preferred learning methods, and interest in a proposed AR-based, 2 × 90-min in-person course. Results: A total of 101 students and 27 lecturers participated. Support for AR in small-group teaching was strong: 96.3% of students and 90.9% of lecturers saw value in a dedicated AR course. Both groups favored its application in anatomy, cardiac surgery, and internal medicine. Students prioritized congenital heart defects, coronary anomalies, and arrhythmias, while lecturers also emphasized invasive valve interventions. Conclusions: There is significant interest in AR-based teaching in cardiovascular education, suggesting its potential to complement and improve traditional methods in medical curricula. Further studies are needed to assess the potential benefits regarding learning outcomes.

BACKGROUND:Stroke after durable left ventricular assist device (d-LVAD) implantation portends high mortality. The incidence of ischemic and hemorrhagic stroke and the impact on stroke outcomes of temporary mechanical circulatory support (tMCS) management among patients requiring bridge to d-LVAD with micro-axial flow-pump (mAFP, Abiomed) is unsettled.METHODS:Consecutive patients, who underwent d-LVAD implantation after being bridged with mAFP at 19 institutions, were retrospectively included. The incidence of early ischemic and hemorrhagic stroke after d-LVAD implantation (<60 days) and association of pre-d-LVAD characteristics and peri-procedural management with a specific focus on tMCS strategies were studied.RESULTS:Among 341 patients, who underwent d-LVAD implantation after mAFP implantation (male gender 83.6%, age 58 [48-65] years, mAFP 5.0/5.5 72.4%), the early ischemic stroke incidence was 10.8% and early hemorrhagic stroke 2.9%. The tMCS characteristics (type of mAFP device and access, support duration, upgrade from intra-aortic balloon pump, ECMELLA, ECMELLA at d-LVAD implantation, hemolysis, and bleeding) were not associated with ischemic stroke after d-LVAD implant. Conversely, the device model (mAFP 2.5/CP vs. mAFP 5.0/5.5: HR 5.6, 95%CI 1.4-22.7, p = 0.015), hemolysis on mAFP support (HR 10.5, 95% CI 1.3-85.3, p = 0.028) and ECMELLA at d-LVAD implantation (HR 5.0, 95% CI 1.4-18.7, p = 0.016) were associated with increased risk of hemorrhagic stroke after d-LVAD implantation. Both early ischemic (HR 2.7, 95% CI 1.9-4.5, p < 0.001) and hemorrhagic (HR 3.43, 95% CI 1.49-7.88, p = 0.004) stroke were associated with increased 1-year mortality.CONCLUSIONS:Among patients undergoing d-LVAD implantation following mAFP support, tMCS characteristics do not impact ischemic stroke occurrence, while several factors are associated with hemorrhagic stroke suggesting a proactive treatment target to reduce this complication.

BACKGROUND:Due to its high impact on quality of life and mental health, close monitoring and often psychotherapy is recommended for patients with a ventricular assist device (VAD). This study investigates the psychological comorbidity and the corresponding psychotherapeutic treatment situation of VAD patients. Special attention is also given to the professional perspective VAD team (assistant and senior cardiologists and specialized nurses). METHODS:We conducted a cross-sectional observational study. Data from 50 VAD patients (mean age = 53.52, standard deviation = 13.82 years, 84.0% male) and their VAD team were analyzed. The presence of a psychological disorder was evaluated by structured clinical interviews for DSM-IV (SCID-I-Interviews). Patients answered a questionnaire regarding their current psychotherapeutic treatment status and their attitude towards psychotherapy. The VAD team answered a questionnaire about the patients' needs for psychotherapy and indicated whether they addressed this topic with the patient. Data were analyzed descriptively, by analysis of variance and t-test. RESULTS:A total of 58% of VAD patients suffered from at least one significant psychological disorder, 79.3% of those were not in psychotherapy. The VAD team could not identify the patients who suffered from a psychological disorder (F = 1.90; p = 0.18). They perceived more need for psychotherapy than they addressed with their patients (T = 3.39; p < 0.001). CONCLUSIONS:While there is a high psychological morbidity among VAD patients, only few receive psychotherapy. Psychological comorbidity is not easily detected by the VAD team. Standardized psychosocial care could be implemented by regular psychological assessments and further information of patients and their VAD teams.

Left ventricular assist devices (LVAD) for patients with terminal heart failure (HF) have become a standard treatment option for patients, however, driveline (DL)-associated infections seriously contribute to morbidity and mortality in this patient cohort and fully implantable system are not available so far.1,2 Up to 20% of LVAD patients developed driveline infection (DLI) within 1 year after implantation.3 The MOMENTUM 3 trial revealed an increased mortality rate in the infection group. The authors state the importance of the link between infection-related complications and postoperative outcome.4 In a study by Kranzl et al.,5 as stated in this current article by Schachl et al.,6 the authors examined the mechanical DL features of the HeartMate3 (HM3) (Abbott Laboratories, North Chicago, IL) and its impact on DLI. They found that the HM3 has unfavorable mechanical DL characteristics, with a large diameter, higher stiffness, and lower flexibility. These features may cause more trauma to the abdominal wall at the driveline exit site (DLES).5 The HM3 is currently the only commercially available LVAD with its documented unfavorable DL features. For surgeons, LVAD coordinators and care takers the question on how to best address the crucial issue of DLI is often answered by center-specific experience. Currently, there is no consensus on best practice in how to treat DLI and in how to best prevent DLI and trauma. These questions were addressed by Schachl et al.6 in their study and they provide a scientific approach in analyzing mechanical features of different DL anchoring systems.6 So far, the anchoring devices were often chosen due to recommendations from companies. Schachl et al.'s6 approach was first to identify different systems through a literature review by contacting international VAD implanting centers and by providing the readers with a vast overview and in vitro data. In this study, eight different fixation systems were tested for tensile strength in an in vitro study. Of these, four anchoring devices withstood a higher tensile force. The central finding in this analysis is that the selection of an appropriate LVAD anchoring device plays a critical role in reducing the risk of DLIs.6 Regardless of the anchoring device used, fixation at 90° provided less tensile forces on the DLES compared with a fixation at 0°. Even the low performing anchoring devices showed less tensile forces at 90° compared with the high performers at 0° fixation angle. This finding emphasizes the importance of surgical position of the DLES and the abdominal positioning of the anchoring device.6 However, it is also important to verify a correlation of these experimental findings in a clinical setting in LVAD patients with DLI. Because an abdominal model with a silicone surface was used, the influence of skin moisture, oiliness, and skin tolerance could not be tested. Other mechanical issues to focus on in future research are the rigidity of the DL and the avoidance of adhesive residue on the smooth surface of the DL which can cause hygiene problems. The size of the adhesive plate plays a role in very small patients, so it would also be interesting to see what force/cm2 is possible with these plates. Another criterion for selection of an anchoring device are ingredients that can trigger allergies, as well as easy handling by the patients, as well as their availability in different countries. At present, the HM3 is the only permanent LVAD option and devices without a DL for power source connection are still solutions of the future. In the meantime, prevention of DLI to reduce the risk of mortality and morbidity is an effective and vital strategy to reduce adverse events such as systemic infections with serious consequences. Schachl et al.6 offer a valuable solution for the time being in the prevention of DLES trauma and provide the impetus for more studies in fixation systems. They offer evidence of benefits in the right selection of anchoring devices and additional insight into the causes and prevention of dreaded LVAD-related complications such as DLI.

AIM:To evaluate the predictive value of preoperative echocardiographic parameters for occurrence of VAs in patients with preexisting ICD undergoing LVAD implantation. METHODS AND RESULTS:All consecutive patients (n = 264) with previous ICD who underwent LVAD surgery between May 2011 and December 2019 at our institution were included. The patients were predominantly male (89%) with NICM (59%) and a mean age of 59 ± 10 years. All LVADs were continuous flow device (154 HVAD, 21 HeartMate II, and 89 HeartMate 3). A total of 102 (39%) patients had VAs in the first year after LVAD implantation. We compared echocardiographic parameters in patients with and without VAs before LVAD, at 1 month and 1 year after LVAD implantation. Increased pre-LVEDD ≥ 72 mm predicted the occurrence of VAs after LVAD implantation for ICM patients (HR: 2.9, 95% confidence interval (CI): [1.3-6.6], p = 0.012), while a larger pre-RVEDD ≥ 46 mm was predictive in NICM patients (HR: 2.8, (CI): [1.4-5.9], p = 0.004). Moreover, a larger RVEDD at 1 year after LVAD was highly associated with VAs in the first year after LVAD implantation (50 ± 10 vs. 45 ± 8 mm, p = 0.001). All patients demonstrated a significant decrease in LVEDD as well as a reduction in severity of mitral and tricuspid regurgitation during 1 year after LVAD implantation, reflecting left ventricular unloading through the LVAD. CONCLUSIONS:Larger left and right ventricular diameters before LVAD predict the occurrence of VAs after LVAD implantation in ICM and NICM patients. Persistent RV remodeling post-LVAD is also associated with VAs.

OBJECTIVE:During a transcatheter aortic valve implant (TAVI) procedure, intraprocedural complications that are manageable only by conversion to emergency open-heart surgery (E-OHS) occasionally occur. Contemporary data on the incidence and outcome of TAVI patients undergoing E-OHS are scarce. This study aimed to evaluate early and midterm outcomes following E-OHS of patients undergoing TAVI in a large tertiary care centre with immediate surgical backup availability for all TAVI procedures over a 15-year period. METHODS:Data from all patients undergoing transfemoral TAVI between 2006 and 2020 at the Heart Centre Leipzig were analysed. The study time was divided into 3 periods: 2006-2010 (P1), 2011-2015 (P2) and 2016-2020 (P3). Patients were grouped according to their surgical risk (high risk: EuroSCORE II ≥ 6%; low/intermediate risk: EuroSCORE II <6%). Primary outcomes were intraprocedural and in-hospital death and 1-year survival. RESULTS:During the study period, a total of 6903 patients underwent transfemoral TAVI. Among them, 74 (1.1%) required E-OHS [high risk, n = 66 (89.2%); low/intermediate risk, n = 8 (10.8%)]. The rate of patients requiring E-OHS was 3.5% (20/577 patients), 1.8% (35/1967 patients) and 0.4% (19/4359 patients) in study periods P1 to P3, respectively (P < 0.001). The proportion of patients who had E-OHS who were low/intermediate risk increased considerably over time (P1:0%; P28.6%; P3:26.3%; P = 0.077). Intraprocedural deaths occurred in 10 patients (13.5%), all of whom were high-risk. In-hospital mortality was 62.1% in high-risk patients and 12.5% in low/intermediate risk patients (P = 0.007). One-year survival was 37.8% in all patients undergoing E-OHS, 31.8% in high-risk patients and 87.5% in low/intermediate risk patients (log-rank P = 0.002). CONCLUSIONS:In-hospital and 1-year survival rates following E-OHS are higher in low/intermediate risk than in high-risk patients undergoing TAVI. An on-site cardiac surgical department with immediately available E-OHS capabilities is an important component of the TAVI team.

Increasing evidence suggests that dalbavancin is an effective long-term treatment for ventricular assist device (VAD) infections, with various prolonged dosing regimens currently in use. This retrospective study aimed to assess dalbavancin pharmacokinetics in VAD patients and identify optimal, feasible dosing regimens for long-term suppressive outpatient therapy. Data from Heidelberg University Hospital’s VAD register were analyzed using non-linear mixed-effects modeling for pharmacokinetic analysis and dosing simulations (Lixoft®). The probability of target attainment (PTA) and cumulative fraction of response (CFR) were calculated for different protein-binding scenarios considering the minimum inhibitory concentration (MIC) distribution of Staphylococcus aureus. Using data from 13 patients with 38 blood samples, a two-compartment model best described the dalbavancin pharmacokinetics, with a typical value for clearance of 0.050 L/h, central volume of distribution of 6.5 L, and peripheral volume of 15.4 L. No covariates significantly improved the model fit. The observed protein binding varied between 96 and 98%. Dosing simulations demonstrated that 1500 mg every 3 weeks ensured the target attainment for stasis at MIC values of 0.125 mg/L (PTA ≥ 90%) up to a protein binding of 99%. Considering the CRF, longer dosing intervals up to 5 weeks might be possible. Depending on individual MICs and protein binding, a dalbavancin regimen of 1500 mg every 3 to 5 weeks therefore appears to be a valuable option for outpatient therapy of VAD infections. Therapeutic drug monitoring should be considered to manage inter-individual variability and to support clinicians in long-term treatments of subacute and chronic infections.

In recent years, SGLT2 inhibitors have become an integral part of heart failure therapy, and several mechanisms contributing to cardiorenal protection have been identified. In this study, we place special emphasis on the atria and investigate acute electrophysiological effects of dapagliflozin to assess the antiarrhythmic potential of SGLT2 inhibitors. Direct electrophysiological effects of dapagliflozin were investigated in patch clamp experiments on isolated atrial cardiomyocytes. Acute treatment with elevated-dose dapagliflozin caused a significant reduction of the action potential inducibility, the amplitude and maximum upstroke velocity. The inhibitory effects were reproduced in human induced pluripotent stem cell-derived cardiomyocytes, and were more pronounced in atrial compared to ventricular cells. Hypothesizing that dapagliflozin directly affects the depolarization phase of atrial action potentials, we examined fast inward sodium currents in human atrial cardiomyocytes and found a significant decrease of peak sodium current densities by dapagliflozin, accompanied by a moderate inhibition of the transient outward potassium current. Translating these findings into a porcine large animal model, acute elevated-dose dapagliflozin treatment caused an atrial-dominant reduction of myocardial conduction velocity in vivo. This could be utilized for both, acute cardioversion of paroxysmal atrial fibrillation episodes and rhythm control of persistent atrial fibrillation. In this study, we show that dapagliflozin alters the excitability of atrial cardiomyocytes by direct inhibition of peak sodium currents. In vivo , dapagliflozin exerts antiarrhythmic effects, revealing a potential new additional role of SGLT2 inhibitors in the treatment of atrial arrhythmias.