Abstract Background Infective endocarditis (IE) is still a serious disease, with a high mortality despite cardiac surgery and modern conservative therapy. However, data on long-term follow-up are sparse. Methods Retrospective single centre registry on the hospital course and long-term follow-up of patients with IE who have undergone cardiac surgery or a conservative therapy with and without an indication for cardiac surgery. Results Between 1/2013 and 12/2016, 171 IE patients were treated at our hospital. A follow-up with either patient contact, review of hospital charts or physician contact was performed in 2022. Due to lost to follow-up (n=4) or refusal to participate after discharge (n=1), the final evaluation was performed with 166 patients (97.1%). They were followed-up for a median 2385.0 (between 2156 and 2773) days. 139 (81.3%) of the patients were operated (surgery) and 32 (18.7%) were treated conservatively. Amongst the conservatively treated group, 34.4% (11/32) of the patients had an indication for surgery, but it was decided not to perform it (cons-with) and 65.6% (21/32) had no indication for surgery (cons-without). Operated patients were younger compared to cons treated patients (65.1 ± 13.0 vs 72.8 ± 15.7, p = 0.00016). Whereas hospital mortality was not different between both groups (21.6 % vs 21.9 %, p = 0.97112), calculated 5y mortality was higher in der cons treated group (71.0 % vs 49.6 %, p=0.03168). Conclusions These data on long-term follow-up after IE show a high total mortality amongst all patients regardless of type of therapy, but higher mortality rate after 5 years amongst conservative treated patients (71%) compared toa surgical treated (49.6% p= 0.03168). The highest mortality rate after 5 years (100%) was detected in the cons-with compared to 55% in the cons-without group. More than 2/3 of deaths were due to IE. However, operated patients were younger and had less co-morbidities. Furthermore, rehospitalisation rate for recurrent IE was also high.

Background The benefits of minimally invasive techniques in cardiac surgery remain poorly defined. We evaluated the short- and mid-term outcomes after surgical aortic valve replacement through partial upper versus complete median sternotomy (MS) in a large, German multicenter cohort. Methods A total of 2,929 patients underwent isolated surgical aortic valve replacement via partial upper sternotomy (PUS, n = 1,764) or MS ( n = 1,165) at nine participating heart centers between 2016 and 2020. After propensity-score matching, 1,990 patients were eligible for analysis. The primary end point was major adverse cardiac and cerebrovascular events (MACCE), a composite of death, myocardial infarction, and stroke at 30 days and in follow-up, up to 5 years. Secondary end points were acute kidney injury, length of hospital stay, transfusions, deep sternal wound infection, Dressler's syndrome, rehospitalization, and conversion to sternotomy. Results Unadjusted MACCE rates were significantly lower in the PUS group both at 30 days ( p = 0.02) and in 5-year follow-up ( p = 0.01). However, after propensity-score matching, differences between the groups were no more statistically significant: MACCE rates were 3.9% (PUS) versus 5.4% (MS, p = 0.14) at 30 days, and 9.9 versus 11.3% in 5-year follow-up ( p = 0.36). In the minimally invasive group, length of intensive care unit (ICU) stay was shorter ( p = 0.03), Dressler's syndrome occurred less frequently ( p = 0.006), and the rate of rehospitalization was reduced significantly ( p < 0.001). There were 3.8% conversions to full sternotomy. Conclusion In a large, German multicenter cohort, MACCE rates were comparable in surgical aortic valve replacement through partial upper and complete sternotomies. Shorter ICU stay and lower rates of Dressler's syndrome and rehospitalization were in favor of the partial sternotomy group.

Indications for TF-TAVI (transfemoral transcatheter aortic valve implantation) are rapidly changing according to increasing evidence from randomized controlled trials. Present trials document the non-inferiority or even superiority of TF-TAVI in intermediate-risk patients (STS-Score 4–8%) as well as in low-risk patients (STS-Score < 4%). However, risk scores exhibit limitations and, as a single criterion, are unable to establish an appropriate indication of TF-TAVI vs transapical TAVI vs SAVR (surgical aortic valve replacement). The ESC (European Society of Cardiology)/EACTS (European Association for Cardio-Thoracic Surgery) guidelines 2017 and the German DGK (Deutsche Gesellschaft für Kardiologie)/DGTHG (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie) commentary 2018 offer a framework for the selection of the best therapeutic method, but the individual decision is left to the discretion of the heart teams. An interdisciplinary TAVI consensus group of interventional cardiologists of the ALKK (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V.) and cardiac surgeons has developed a detailed consensus on the indications for TF-TAVI to provide an up-to-date, evidence-based, comprehensive decision matrix for daily practice. The matrix of indication criteria includes age, risk scores, contraindications against SAVR (e.g., porcelain aorta), cardiovascular criteria pro TAVI, additional criteria pro TAVI (e.g., frailty, comorbidities, organ dysfunction), contraindications against TAVI (e.g., endocarditis) and cardiovascular criteria pro SAVR (e.g., bicuspid valve anatomy). This interdisciplinary consensus may provide orientation to heart teams for individual TAVI-indication decisions. Future adaptations according to evolving medical evidence are to be expected. Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI).

A new calculation of the Ecological Footprint (EF) of a water provider addresses limitations in the previous methodology by regionalising a previously national input-output model, and determining the area of disturbance caused by environmental toxicants not considered in the traditional EF model. In a first step, the regional input-output model determines indirect ef fects of water services activities in the form of point sources of pollutants. Accuracy is im proved by hybridisation using "process data" to account for the direct environmental burden of the water service. The accuracy of the input-output model is improved by reconciling data sources; calibrating concordance tables and employing optimisation techniques to deal with conflicting data sources. The second step involves a nested fate model, which follows the fate of the point source emissions at several spatial scales. The final output provides an indication of the direct and indirect burden connected with the water business, throughout its entire upstream supply chains. This proposed EF methodology improves on previous EF methodologies by avoiding exclusive reliance on national average data, and by including toxicants in a disturbance-based calculation analogous to the established inclusion of green house gases in EF, making it more comprehensive. It is hoped that the additional detail and comprehensiveness will make the new method a more effective environmental reporting and communications tool for the Australian water industry. This generic approach to environ mental reporting may potentially be applied to other economic activities.

Rationale . Poststernotomy pain and impaired breathing are common clinical problems in early postoperative care following heart surgery. Insufficiently treated pain increases the risk of pulmonary complications. High-dose opioids are used for pain management, but they may cause side effects such as respiratory depression. Study Design . We performed a prospective, randomized, controlled, observer-blinded, three-armed clinical trial with 100 patients. Group 1 (n=33) and Group 2 (n=34) received one 20 min session of standardized acupuncture treatment with two different sets of acupoints. Group 3 (n=33) served as standard analgesia control without additional intervention. Results. Primary endpoint analysis revealed a statistically significant analgesic effect for both acupuncture treatments. Group 1 showed a mean percentile pain reduction (PPR) of 18% (SD 19,P<0.001). Group 2 yielded a mean PPR of 71% (SD 13,P<0.001). In Group 1, acupuncture resulted in a mean forced vital capacity (FVC) increase of 30 cm 3 (SD 73) without statistical significance (P=0.303). In Group 2, posttreatment FVC showed a significant increase of 306 cm 3 (SD 215,P<0.001). Conclusion . Acupuncture revealed specific analgesic effects after sternotomy. Objective measurement of poststernotomy pain via lung function test was possible.

Bei einem 53-jährigen Patienten mit progredienter Belastungsdyspnoe und ausgeprägter linksventrikulärer Hypertrophie wurde in einer Myokardbiopsie nach Kongorotfärbung Amyloid festgestellt. Immunhistochemisch stellte sich dieses als TTR-Amyloid dar. Bei molekulargenetischem Nachweis einer Val20Ile-Mutation im Transthyretingen war die Diagnose einer hereditären Amyloidose gesichert. Aufgrund klinischer und hämodynamischer Verschlechterung erfolgte eine Listung zur Herztransplantation, die innerhalb des nächsten Jahres erfolgreich durchgeführt werden konnte. Zwei leichte Rejektionen in den ersten 6 Monaten nach der Transplantation wurden jeweils mit einem Kortisonstoß behandelt. Der weitere postoperative Verlauf gestaltete sich über mehr als 7 Jahre komplikationslos ohne Hinweis für eine Rekurrenz des Amyloids im Herztransplantat.

A 53 year-old male patient presented with exertional dyspneoa and massive left ventricular hypertrophy. Endomyocardial biopsy with Congo red staining and immunohistochemistry revealed transthyretin amyloid deposition. By genetic testing Val20Ile mutation was observed in the transthyretin gene, thus confirming diagnosis of hereditary transthyretin amyloidosis. Due to clinical and hemodynamic worsening the patient was referred for heart transplantation that was performed successfully within one year. The postoperative course was unremarkable except for two episodes of graft rejection without any hemodynamic deterioration that were treated with steroids. The patient is doing very well for more than seven years without any evidence of amyloid recurrence in the graft.

Background. Calcineurin inhibitor (CNI)-free immunosuppression is used increasingly after heart transplantation to avoid CNI toxicity, but in the absence of a randomized trial, concerns remain over an increased rejection risk.Methods. We studied the incidence of graft rejection episodes among all cardiac graft recipients, beginning with the first introduction of CNI-free protocols. We compared events during CNI-free and CNI-containing immunosuppression among 231 transplant recipients of overall mean age 55.2 +/- 11.8 years, from a mean 5.2 +/- 5.4 years after transplantation through a mean follow-up of 3.1 +/- 1.4 years. We considered as acute rejection episodes requiring treatment those of International Society for Heart and Lung Transplantation.Results. During the total follow-up of 685 patient years (CNI-containing, 563; CNI-free, 122), we performed 1,374 biopsies which diagnosed 78 rejection episodes. More biopsies were performed in CNI-free patients: biopsies/patient-month of CNI-containing, 0.13 versus CNI-free, 0.22 (P < .05). The incidence of rejection episodes per patient-month was significantly higher on CNI-free compared with CNI therapy, among patients switched both early and later after heart transplantation, namely, within 1 year, 0.119 versus 0.035 (P = .02); beyond 1 year, 0.011 versus 0.004 (P = .007); beyond 2 years, 0.007 versus 0.003 (P = .04); and beyond 5 years: 0.00578 versus 0.00173 (P = .04).Conclusions. Rejection incidence during CNI-free immunosuppression protocols after heart transplantation was significantly increased in both early and later postoperative periods. Given the potentially long delay to rejection occurrence, patients should be monitored closely for several months after a switch to CNI-free immunosuppressive protocols.

We report the case of a 63-year-old man with ischemic cardiomyopathy having an implantable cardioverter defibrillator (ICD) implanted for repeated ventricular tachycardia (VT). After several revisions of the ICD lead, a thrombosis of the left venous system was diagnosed. A right pectoral ICD device was implanted, and a sufficient defibrillation threshold (DFT) could not be achieved during the operation. Thus, a further defibrillation lead was implanted into the coronary sinus, which successfully terminated ventricular fibrillation.

The objectives of the present study were to evaluate the incidence of malignancies and to describe the effects of immunosuppression on survival and recurrence of malignancies after heart transplantation (HTX). Data were analyzed in 211 cardiac allograft recipients, in whom HTX was performed between 1989 and 2005. All of these patients survived for more than 2 years after HTX and received induction therapy with antithymocyte globulin (RATG) guided by T-cell monitoring since 1994. An immunosuppressive regimen consisting of cyclosporine A (CsA) combined with azathioprine was followed by CsA and mycophenolate mofetil (MMF) in 2001; mammalian target of rapamycin (mTOR) inhibitors (everolimus/sirolimus) were used since 2003. Mean patient age at HTX was 51.4 ± 10.5 years; mean follow-up time after HTX 9.2 ± 4.7 years. Overall incidence of neoplasias was 30.8%. Individual risk factors associated with a higher risk of malignancy after HTX were higher age at transplantation (P = .003), male gender (P = .005) and ischemic cardiomyopathy before HTX (P = .04). Administration of azathioprine (P < .0001) or a calcineurin inhibitor (CNI) (P = .02) for more than 1 year was associated with development of malignancy, whereas significantly fewer malignancies were noticed in patients receiving an mTOR-inhibitor (P < .0001). Kaplan-Meier analysis demonstrated a strong statistical trend toward an improved survival in patients with a noncutaneous neoplasia switched to a CNI-free protocol (P = .05). This study demonstrated the impact of a variety of individual risk factors and immunosuppressive drugs on development of malignancy after HTX. Markedly fewer patients with noncutaneous malignancies died after switch to a CNI-free regimen, not quite reaching statistical significance by Kaplan-Meier analysis, however.

Objective. Effective myocardial preservation is an important condition for cardiac surgery, especially in heart transplantation with long ischemia times. During ischemia and reperfusion, myocardial function is altered by cold-induced ischemic injury. Cold-induced ischemic injury is triggered by cold storage and the amino acid histidine, a main component of the storage solution histidine-tryptophan-ketoglutarate (HTK). Cold-induced ischemic injury generates free oxygen radicals in an iron-dependent way. We investigated the efficacy of new modifications with the addition of L-arginine and N-alpha-acetyl-histidine to the well-established HTK solution (Custodiol) using a rat heart transplant model.Materials and Methods. Heterotopic transplantation was performed in Lewis rats (n = 20). After I hour of ischemic preservation and I hour of reperfusion, we assessed myocardial function and energy charge potential. The modifications of HTK solution included the addition of L-arginine, partial replacement of histidine with acetyl-histidine, and reduction of chloride concentration (HTK-1). In a second group, Custodiol served as the control.Results. After 1 hour of reperfusion, left ventricular systolic pressure (106 +/- 33 vs 69 9 mm Hg; P < .05) and minimum rate of pressure development (dP/dt) (-1388 +/- 627 vs - 735 +/- 219 mm Hg/s; P < .05) were significantly higher among the HTK-1 group compared with the control group. Energy charge potential did not differ significantly between the groups.Conclusion. This study showed that the novel modified HTK-1 solution improved myocardial contractility and relaxation after heart transplantation.

Graft denervation in heart transplant recipients causes sinus tachycardia, occasionally requiring pharmacologic heart rate reduction. In patients after heart transplantation (HTX), currently no long-term data regarding effects of the novel If channel antagonist ivabradine regarding heart rate control, left ventricular (LV) mass, tolerability, and safety are available.

Calcineurin inhibitor-free (CNI-free) immunosuppression is used increasingly after heart transplantation to avoid CNI toxicity, but concerns remain over increased rejection risk in the absence of a randomized trial.

Backround. Infections and rejections play key roles in morbidity and mortality in the early postoperative period after orthotopic heart transplantation (HTX). The aim of this study was to evaluate whether qualitative and quantitative analyses of various interstitial leukocytes in endomyocardial biopsies during the first 2 weeks after HTX provided early information on these complications.Patients and Methods. During and after HTX, endomyocardial biopsies were obtained in 51 patients. By immunohistochemistry we determined the CD3-, CD4-, CD8-, CD15-, CD20-, CD57-, and CD68-positive cell numbers projected to planimetrically measured areas. To compare morbidity in the postoperative course, the patients were subdivided into complicated versus uncomplicated after 3 months.Results. In the uncomplicated group, the cell counts of CD3-, CD8-, CD57-, and CD68-positive cells were significantly lower than in the complicated group. CD3-, CD4-, and CD8-positive cell numbers showed a significant decrease in the first week among the uncomplicated group. In the complicated group, the cell counts increased significantly in the second week. The numbers of CD57-positive cells were significantly lower during the first and second weeks among the uncomplicated group.Conclusions. Increased T lymphocytes, natural killer cells, and macrophages observed in the second week after HTX indicated increased morbidity. A reduction in CD3-positive cells in the first week indicated a low morbidity risk; an increase indicated a higher risk.

A revised methodology for calculating ecological footprints is proposed. The method considers anthropogenic disturbances at a finer level of geographical desegregation than previous methods; instead of a single national land area it considers 1408 smaller regions within Australia. It also addresses a previous gap in disturbance-based ecological footprint calculation, that is, the exclusion of ecotoxic emissions. The method is described and illustrated using a case study. The resulting ecological footprint is larger than previous calculations, but it avoids a current methodological problem in which the energy used to treat exhaust gases or wastewaters increases the ecological footprint of communities without any corresponding benefit associated with reduced emissions to the environment.

Objective. Acute rejection may lead to cell death following heart transplantation. Programmed cell death (apoptosis) has been described as a cofactor for cell loss in cardiac tissue. The aim of our study was to quantify the amount and extent of apoptotic cells during acute rejection episodes after orthotopic heart transplantation.Patients and Methods. Right ventricular biopsies from 27 heart transplant recipients were classified histologically according to rejection grade. Formalin-fixed sections were processed for immunohistochemistry. TUNEL-positive cells were counted and the expression of apoptosis-modulating factors Bax, Bcl-x(L), Bcl-2, and Ki-67 (proliferation marker) was scored. P <= .05 was considered statistically significant.Results. The total amount of TUNEL-positive interstitial cells was 1.5/mm(2) and 1/mm(2) for cardiomyocytes. The number of TUNEL-positive interstitial cells was found to be significantly higher in high-grade rejection. The anti-apoptotic Bcl-2 was expressed significantly higher in interstitial cells during high-grade rejection, whereas in cardiomyocytes there were no differences regarding Bcl-2 expression. There were no significant differences in the expression of Bcl-x(L) and Bax. The proliferation marker Ki-67 was not positive in cardiomyocytes. In interstitial cells the expression did not differ between low-and high-grade rejection.Conclusions. The current study demonstrated the presence of apoptotic cell death during acute rejection episodes in human heart transplants. Interstitial cells were affected almost exclusively, whereas apoptosis of cardiomyocytes was hardly detectable. However, the amount of apoptotic cells was too low to have a significant impact on organ function. Moreover, the anti-apoptotic Bcl-2 could be found in interstitial cells and seemed to have an apoptosis-protective effect in acute high-grade rejection.