Background/Objectives: Transcatheter aortic valve implantation (TAVI) has become the leading treatment option for patients suffering from aortic valve stenosis aged over 70, except in cases of specific contraindications like bicuspid valves, inappropriate access routes, or endocarditis. Minimally invasive aortic valve replacement (MIAVR) has emerged as a potential way to combine the durability of surgery with reduced procedural trauma. This study aims to assess the safety and feasibility of MIAVR in elderly patients. Methods: A total of 990 patients were included in this retrospective cohort study. Among them, 261 (26%) were aged 70 years or older (elderly cohort), and 729 (74%) were younger than 70 years (younger cohort). All patients were followed for at least 30 days postoperatively, with survival data collected through May 2025. Multivariable logistic regression, linear regression, and Kaplan-Meier survival analyses were performed. Results: Elderly patients were more likely to be female (51% vs. 40%, p = 0.001) and carried a heavier burden of vascular and renal comorbidity: renal impairment 33% vs. 17% and extracardiac arteriopathy 45% vs. 30% (both p < 0.001). Major bleeding occurred more frequently in the elderly cohort (7.7% vs. 4.1%; p = 0.02), as did new permanent pacemaker implantation (10% vs. 5.8%; p = 0.021) and sepsis (3.4% vs. 1.1%; p = 0.012). Rates of stroke, perioperative myocardial infarction, ECMO/right-heart failure, re-thoracotomy, and postoperative dialysis were low and comparable across age groups (all p > 0.20). Overall, 30-day mortality was 2.4% (24/990), with crude mortality approximately threefold higher among patients aged ≥70 years (4.6% vs. 1.6%). Conclusions: Our findings indicate that MIAVR is a feasible and safe surgical option across age groups; Elevated morbidity in elderly patients is primarily due to bleeding, pacemaker implantation, and sepsis, while rates of stroke, renal failure, and myocardial infarction are low.

BACKGROUND:Consensus regarding on-support evaluation and weaning concepts from Impella 5.5 support is scarce. The derived left ventricular end-diastolic pressure (dLVEDP), estimated by device algorithms, is a rarely reported tool for monitoring the weaning process. Its validation and clinical accuracy have not been studied in patients. We assess dLVEDP's accuracy in predicting pulmonary capillary wedge pressure (PCWP) and propose a corrective equation. METHODS:We included 29 consecutive patients treated with Impella 5.5: 12 in a generation cohort and 17 in a validation cohort. dLVEDP and PCWP were measured 5-fold every 8 hours during support, totaling 698 series with 3490 measurements. Variables such as Impella 5.5 performance level, heart rhythm, pacemaker settings, sex, mechanical ventilation, and body mass index were recorded. Linear regression was used to correct dLVEDP-PCWP discrepancies. Analysis included Bland-Altman plots, linear regression, histograms, and violin plots. RESULTS:The raw dLVEDP and PCWP data did not coincide satisfactorily. The Impella 5.5 dLVEDP overestimation was 3.5±1.5 mm Hg (mean±SD), increasing with higher pressures and unaffected by cardiac rhythm, mechanical ventilation, and performance levels. Statistical correction using the formula modified dLVEDP=-0.457+(1-sex[1=male, 0=female])×0.719-0.0496× body mass index+1.015×body surface area+0.811×dLVEDP significantly reduced the overestimation (P<0.01) to 0.0±1.2 mm Hg. CONCLUSIONS:dLVEDP, calculated by the Impella 5.5 Smart Algorithm, is a feasible and effective tool for continuously monitoring PCWP at performance levels 3 to 9. Correction of dLVEDP by using the described equation further enhances its accuracy. Hence, hemodynamic surveillance via dLVEDP may aid in managing and weaning temporary microaxial support, potentially reducing the need for continuous monitoring with a Swan-Ganz catheter.

Volatile anesthetics are known to be potent greenhouse gases and a significant source of per-and polyfluoroalkyl substances (PFAS) “forever chemical” pollution. The latter is arguably an additional strong reason to stop the emission of anesthetic exhaust gases into the atmosphere on its own. In clinical practice large proportions of used volatile anesthetics are released into the environment via anesthetic gas scavenging systems. Anesthetic gas adsorbers have been developed to bind volatile anesthetics for later extraction and reusage. They may have the potential to replace anesthetic gas scavenging systems which would have a beneficial effect on the energy consumption of hospitals. However, studies are needed to ensure effective elimination of volatile anesthetics via anesthetic gas adsorbers without gas scavenging systems. To evaluate an anesthetic gas adsorber during simulated ventilation. A bench study. An anesthesia machine was connected to an anesthetic gas adsorber (CONTRAfluran™ system, Zeosys Medical, Luckenwalde, Germany) without the use of an anesthetic gas scavenging system. A test lung was ventilated with sevoflurane and oxygen. Sevoflurane concentrations in parts per million (ppm) were detected directly from the anesthetic gas adsorber exhaust outlet using ion mobility spectrometry with gas chromatographic preseparation. A total of 6 experiments were conducted with alternating fresh gas flows, sevoflurane concentrations, humidified air and CO2 insufflation. Absolute sevoflurane concentration. Sevoflurane concentration remained < 1 ppm as long as the canisters were not saturated. At higher fresh gas flow, the breakthrough time of the anesthetic gas adsorber decreased proportionately. Humidified air and CO2 insufflation had only a minor influence on the breakthrough time. The anesthetic gas adsorber did not leak relevant sevoflurane concentrations through the exhaust outlet when used without an anesthetic gas scavenging system. When the canister came close to saturation, the post adsorber exhaust sevoflurane concentration progressively increased–indicated by first the yellow-light and subsequently the red-light warning of the anesthetic gas adsorber system. Continuation of the ventilation with a fully saturated canister resulted in ambient room contamination of up to 12.4 ppm sevoflurane, which though undesirable is still low when compared to mask induction. • Volatile anesthetics are potent greenhouse gases and are released into the atmosphere via anesthetic gas scavenging systems. • Anesthetic gas adsorbers have been developed to capture volatile anesthetics using activated carbon. • This study evaluates if an anesthetic gas adsorber without anesthetic gas scavenging system leaks relevant sevoflurane concentrations during simulated anesthesia. • Sevoflurane concentrations measured directly at the exhaust outlet remained < 1 ppm as long as the adsorber canisters were not saturated. • Breakthrough time was decreased with higher fresh gas flow, while humidity and CO2 had only minor influence.

Background/Objectives: The optimal choice of cardioplegia solution in minimally invasive cardiac surgeries (MICS) remains debated, as prolonged myocardial protection is essential to avoid interruptions to the surgical flow, which can prolong aortic cross-clamp time and cardiopulmonary bypass time, especially in the constrained surgical field. We conducted a network meta-analysis to evaluate the safety and efficacy of the del Nido (DN), histidine-tryptophan-ketoglutarate (HTK), blood cardioplegia (BC), and St. Thomas’ (STH) solutions in MICS. Methods: Medical electronic databases were thoroughly searched without time restrictions, including all types of studies except for study protocols and animal research. The final search was completed in June 2024. Subsequently, a network meta-regression was performed on both primary and secondary endpoints, utilizing R (The R Foundation for Statistical Computing, version 3.6.2) for the analysis. Meta-analyses were carried out using Review Manager software. Results: A total of 15 studies, enrolling 2282 patients, were included in the analysis. None of the comparisons showed statistically significant differences in in-hospital mortality between the four cardioplegia solutions (BC vs. HTK, OR: 3.21, 95% CI: 0.13–80.84; DN vs. HTK, OR: 1.42, 95% CI: 0.28–7.23; STH vs. HTK, OR: 1.25, 95% CI: 0.19–8.20). Conclusions: In this network meta-analysis of cardioplegia solutions in MICS, no significant differences were observed in major clinical outcomes across the solutions. Cardioplegia solutions that provide long-lasting myocardial protection with a single dose, such as DN and HTK, were found to be safely applied in MICS. DN was associated with shorter CPB times and HTK was associated with shorter hospital stays, though these differences may not have clinical implications.

Background/Objectives: Over the past two decades, significant advancements in mitral valve surgery have focused on minimally invasive techniques. Some surgeons consider obesity as a relative contraindication for minimally invasive mitral valve surgery (MIMVS). The aim of this study is to evaluate whether the specific characteristics of obese patients contribute to increased surgical complexity and whether this, in turn, leads to worse clinical outcomes compared to non-obese patients. Furthermore, we aim to explore whether these findings could substantiate the consideration of limiting this treatment option for obese patients. We investigated the outcomes of MIMVS in obese and non-obese patients at a high-volume center in Germany staffed by an experienced surgical team well-versed in perioperative management. Methods: A total of 934 MIMVS were performed in our high-volume center in Germany from 2011 to 2023. Of these, 196 patients had a BMI of 30 or higher (obese group), while 738 patients had a BMI below 30 (non-obese group), all of whom underwent MIMVS by right minithoracotomy. Demographic information, echocardiographic assessments, surgical data, and clinical outcome parameters were collected for all patients. Results: There was no significant difference in in-hospital, 30-day, and late mortality between groups (obese vs. non-obese: 6 [3.0%] vs. 14 [1.8%], p = 0.40; 6 [3.0%] vs. 14 [1.8%], p = 0.40; 13 [6.6%] vs. 39 [5.3%], p = 0.48, respectively). Respiratory insufficiency and arrhythmia occurred more frequently in the obese group (obese vs. non-obese: 25 [12.7%] vs. 35 [4.7%], p < 0.001; 35 [17.8%] vs. 77 [10.4%], p = 0.006). Conclusions: Obesity was not associated with increased early or late mortality in patients undergoing MIMVS. However, obese patients experienced higher incidences of postoperative complications, including respiratory insufficiency, arrhythmias, delirium, and wound dehiscence. Nonetheless, a multivariate logistic regression analysis indicated that obesity itself does not contraindicate MIMVS and should not be viewed as a barrier to offering this minimally invasive approach to obese patients.

Purpose of review Preoperative evaluation of older and more morbid patients in thoracic surgery is getting more advanced. In this context, early risk stratification has a crucial role for adequate informed decision-making, and thus for generating favourable effects of clinical outcome. Recent findings Recent findings confirm that many risk factors impair mortality and morbidity beyond classical medical findings like results of lung function tests and values of the revised cardiac risk index. Especially results from holistic views on patients’ functional status like frailty assessments are linked with long-term survival after lung resection. Summary A comprehensive risk stratification by anaesthesiologists generates valuable guidance for the best strategy of clinical treatment. This includes preoperative, peri-operative and postoperative interventions, provided by interdisciplinary healthcare providers, resulting in an Early Risk Stratification and Strategy (’ERSAS’) pathway.

Lung transplantation has a high risk of haemodynamic complications in a highly vulnerable patient population. The effects on the cardiovascular system of the various underlying end-stage lung diseases also contribute to this risk. Following a literature review and based on our own experience, this review article summarises the current trends and their evidence for intraoperative circulatory support in lung transplantation. Identifiable and partly modifiable risk factors are mentioned and corresponding strategies for treatment are discussed. The approach of first identifying risk factors and then developing an adjusted strategy is presented as the ERSAS (early risk stratification and strategy) concept. Typical haemodynamic complications discussed here include right ventricular failure, diastolic dysfunction caused by left ventricular deconditioning, and reperfusion injury to the transplanted lung. Pre- and intra-operatively detectable risk factors for the occurrence of haemodynamic complications are rare, and the therapeutic strategies applied differ considerably between centres. However, all the mentioned risk factors and treatment strategies can be integrated into clinical treatment algorithms and can influence patient outcome in terms of both mortality and morbidity.

Lung surgery under spontaneous ventilation (non-intubated video-assisted thoracoscopic surgery, niVATS) picked up a lot of momentum during the past few years. Surgeons and anesthetists alike want to forgo known risks of orotracheal intubation and mechanical ventilation, ranging from local complications, like mucosal injury or even deleterious tracheal laceration and rupture, to increased release of pro-inflammatory cytokines and diaphragmatic dysfunction secondary to muscle relaxation. Despite initial adoption of VATS in Germany having been slow due to a general reticence towards it in smaller units, major thoracic centers nowadays have well-established minimally invasive programs and even perform minor non-intubated procedures on a regular basis. Experience with major niVATS cases still is sparse across Western Europe, and limited to specialized and highly trained centers, where exceptionally complex and often multimorbid patients can safely undergo lung surgery under spontaneous ventilation. Our group pioneered niVATS lobectomy in Germany back in 2018, and since then we tried to spread the technique by means of multidisciplinary Masterclass-courses held at our center, in which the participant's initial reticence to perform niVATS often changed to enthusiasm for the procedure. This in turn led several visiting units to start with their own programs, and some of them even reported their initial experience. This article offers a short historic overview of VATS in general, gives an insight into how niVATS got pioneered in Germany and presents the current state of affairs.

ZusammenfassungDie Zahl herz- und lungentransplantierter Patienten wächst stetig und ihre Lebenserwartung steigt. Somit nimmt auch die Wahrscheinlichkeit zu, dass einige dieser Patienten Komorbiditäten entwickeln, die einen chirurgischen Eingriff erfordern. Das perioperative anästhesiologische Management herz- und lungentransplantierter Patienten ist eine große Herausforderung – dieser Beitrag gibt einen Überblick.

Background Non-intubated uniportal video-assisted thoracoscopic surgery (niVATS) is a novel approach to major and minor lung resection. It benefits from a holistic anesthesiological concept with adequate pain relief and sedation in a minimal-invasive setup allowing thoracic procedures under spontaneous breathing. At present no anesthesiological gold standard for niVATS exists. The primary aim of our retrospective observational study was to evaluate feasibility and safety of minimally invasive niVATS for both minor and major pulmonary resections at our institution. Methods All 88 consecutive patients scheduled for niVATS minor or major thoracic procedures were included into the study. Anaesthesia was performed according to a departmental niVATS algorithm including both regional anaesthesia and sedation. Patient characteristics and early outcome data including intraoperative and postoperative findings were compared between groups. Prediction scores for postoperative complications (LAS VEGAS, ARISCAT, ThRCRI) were calculated and compared. Results No early mortality and a low overall morbidity rate of 28.4% were encountered. Conversion to orotracheal intubation was required in 6.8% of all cases. Postoperative pulmonary complications occurred in 15.9% of total cases and were lower than predicted by both LAS VEGAS and ARISCAT respectively. Cardiac complications were found in 1.1% and lower than predicted by ThRCRI. A persistent air leak occurred in 11.4% of total cases and was significantly higher in major resection. Postoperative chest tube duration and hospital length of stay in the major resection group exceeded times reported by other groups. Conclusions niVATS appears to be safe in both minor and major thoracic procedures. A minimally invasive anaesthesiological approach foregoing central iv lines, arterial blood pressure measurement and urinary catheterization is feasible. Our niVATS protocol appears to be a viable alternative for both minor and major thoracic procedures in selected patients.

The outcome after heart and lung transplantation has improved significantly. Consequently, many patients are admitted to the hospital for routine surgical interventions that are initially non-transplant-specific. Some disorders lead to hospital admissions that affect other organ systems due to late consequences of the underlying disease or can be seen as early and late complications of the transplantation itself. Many of these surgical interventions are certainly carried out in the responsible transplant centre. Some surgeries are also performed in hospitals that do not primarily transplant and do not regularly care for heart and lung transplant patients. In these situations, the understanding of the physiology of the transplanted heart and lung, the consequences of the underlying disease and the post-transplant treatment with its peculiarities and risks is paramount. The anaesthetic management of these patients requires preoperative risk stratification and perioperative anaesthetic planning, but also responsibility for a suitable post-operative monitoring. This review article deals with the special anaesthetic consideration in patients after heart and lung transplantation.

There is no agreement on gold standard method for positive end-expiratory pressure (PEEP) titration. Electrical impedance tomography (EIT) may aid in finding the optimal PEEP level. In this pilot trial, we investigated potential differences in the suggested optimal PEEP (BestPEEP) as derived by respiratory compliance and EIT-derived parameters. We examined if compliance-derived PEEP differs with regard to the regional ventilation distribution in relation to atelectasis and hyperinflation. Measurements were performed during an incremental/decremental PEEP trial in 15 ventilated intensive care patients suffering from mild-to-moderate impairment of oxygenation due to sepsis, pneumonia, trauma and metabolic and ischemic disorders. Measurement agreement was analyzed using Bland-Altman plots. We observed a diversity of EIT-derived and compliance-based optimal PEEP in the evaluated patients. BestPEEPCompliance did not necessarily correspond to the BestPEEPODCL with the least regional overdistension and collapse. The collapsed area was significantly smaller when the overdistension/collapse index was used for PEEP definition (p=0.022). Our results showed a clinically relevant difference in the suggested optimal PEEP levels when using different parameters for PEEP titration. The compliance-derived PEEP level revealed a higher proportion of residual regional atelectasis as compared to EIT-based PEEP.

Background Electrical impedance tomography (EIT) is a non-invasive bedside tool which allows an individualized ventilator strategy by monitoring tidal ventilation and lung aeration. EIT can be performed at different cranio-caudal thoracic levels, but data are missing about the optimal belt position. The main goal of this prospective observational study was to evaluate the impact of different electrode layers on tidal impedance variation in relation to global volume changes in order to propose a proper belt position for EIT measurements. Methods EIT measurements were performed in 15 mechanically ventilated intensive care patients with the electrode belt at different thoracic layers (L1-L7). All respiratory and hemodynamic parameters were recorded. Blood gas analyses were obtained once at the beginning of EIT examination. Off-line tidal impedance variation/tidal volume (TV/VT) ratio was calculated, and specific patterns of impedance distribution due to automatic and user-defined adjustment of the colour scale for EIT images were identified. Results TV/VT ratio is the highest at L1. It decreases in caudal direction. At L5, the decrease of TV/VT ratio is significant. We could identify patterns of diaphragmatic interference with ventilation-related impedance changes, which owing to the automatically adjusted colour scales are not obvious in the regularly displayed EIT images. Conclusions The clinical usability and plausibility of EIT measurements depend on proper belt position, proper impedance visualisation, correct analysis and data interpretation. When EIT is used to estimate global parameters like VT or changes in end-expiratory lung volume, the best electrode plane is between the 4th and 5th intercostal space. The specific colour coding occasionally suppresses user-relevant information, and manual rescaling of images is necessary to visualise this information.

Introduction: Pulmonary complications have a major impact on the morbidity and mortality of critically ill patients with multiple trauma. Intraoperative protective ventilation with low tidal volume may prevent lung injury and infection, whereas the role of positive end-expiratory pressure (PEEP) levels is unclear. The aim of this study was to evaluate the influence of different intraoperative PEEP levels on incidence of pulmonary complications after emergency trauma surgery.Material and methods: We retrospectively analysed data of multiple trauma patients who underwent emergency surgery within 24 h after injury in our level I trauma centre (n = 86). On the basis of their intraoperative PEEP level, patients were divided into a low PEEP group with a PEEP of < 8 mbar and a high PEEP group with a PEEP of 8 mbar or higher.Results: Besides differences in body mass index and preoperative oxygenation, there were no differences in patients' baseline data. There was a significant difference between incidence of pneumonia within 7 days after trauma surgery, with an incidence 26.7% in the low PEEP group and 7.3% in the high PEEP group (p = 0.02). The low PEEP group had higher pulmonary infection scores at days 3 and 5 after surgery. Oxygenation was better in the higher PEEP group postoperatively. There was no difference with respect to the incidence of acute respiratory distress syndrome, the mortality up until hospital discharge or haemodynamic parameters between groups.Conclusions: Higher PEEP levels were associated with perioperative improvement of oxygenation and a lower incidence of pneumonia, without impairment of haemodynamics. Additional studies should be initiated to confirm these observations.

Background Previous publications describe house officers (HOs) as unaware of their ineffective teaching skills. Objective The aim of this study was to evaluate the role of teaching seniority in the comparison of teaching skills between HOs and faculty. Materials and methods Ten HOs (F: n=4, M: n=6, age: 35.1±6.8 years) and nine faculty (F: n=3, M: n=6, age: 41.4±4.9 years) who actively teach undergraduate emergency medicine were immediately evaluated at the end of the course by their students using the questionnaire SFDP26. The questionnaire consists of one item on ‘overall teaching effectiveness’ (OTE) (1=very poor to 5=excellent) and 25 items measured on a five-point Likert scale (1–5=strongly disagree to strongly agree) divided into seven subscales: 1, ‘establishing the learning climate’ (LC); 2, ‘control of session’ (CS); 3, ‘communication of goals’ (CG); 4, ‘facilitating understanding and retention’ (UR); 5, ‘evaluation’ (E); 6, ‘feedback’ (FB) and 7, ‘promoting self-directed learning’ (SL). The sample included 173 medical students in their third year of training who were randomly assigned to the instructors. A Mann–Whitney U-test was used to calculate group-related differences (resident vs. teaching faculty). For significant differences, effect size was calculated (r=Z/√N). Results No sex-related differences were found. Significantly better ratings for HOs were found in subscales: 1, ‘LC’ (P=0.001; r=0.20); 2, ‘CS’ (P=0.037; r=0.15); 5, ‘E’ (P=0.007; r=0.20); 6, ‘FB’ (P=0.001; r=0.23); 7, ‘SL’ (P=0.004; r=0.24) and ‘OTE’ (P=0.027; r=0.26). Conclusion From a learner’s perspective, the quality of teaching provided by HOs was rated at least similar and mostly better overall than that provided by faculty. These findings contradict results from previous studies on the quality of HO teaching and therefore warrant further assessment.

It is unclear whether bedside monitoring tools such as exhaled nitric oxide measurements (FENO) and electrical impedance tomography (EIT) could help guiding patient management in community-acquired pneumonia (CAP). We hypothesized that exhaled NO would be increased in CAP patients and could be used to assess resolution of inflammation in the course of CAP therapy. Feasibility of multiple-breath (mb) and single-breath (sb) approach has been investigated. EIT was compared with chest X-ray at admission and used to assess whether the inhomogeneous ventilation changes due to treatment. 24 CAP patients were enrolled. Measurements were accomplished at admission (T0: EIT + FENO), after 3 days (T1: FENO) and 5–6 days after admission (T2: EIT + FENO). We computed an EIT distribution index (DEIT), which reflects the uniformity of ventilation. FENO measurements showed a significant decrease in NO after the beginning of antibiotic therapy [p = 0.04 (sb); p = 0.003 (mb)]. Correlation between sb method and mb method was significant (p < 0.001, r = 0.70). EIT detects right-sided and left-sided ventilation disorders due to pneumonia in correspondence to chest X-ray (p < 0.01). EIT images at T2 showed a more homogeneous ventilation distribution in displayed EIT. FENO could be a prospective supplementary tool to describe local lung inflammation as individual trend parameter. EIT could be a suitable supplementary tool to monitor functional lung status in CAP.

BACKGROUND:Intra-articular injection of local anaesthetics, opioids and corticosteroids is frequently used to obtain perioperative analgesia following joint surgery. Although local anaesthetics were shown to induce chondrotoxicity, the safety profile regarding chondrotoxicity of other injected drugs is less clear.OBJECTIVE:Our objective was to investigate cytotoxicity of drugs used for intra-articular analgesia.DESIGN:An experimental in-vitro study.SETTING:Hannover Medical School, science laboratory, 2013.MATERIAL:Human cartilage cell line T/C 28-a2.INTERVENTION:Incubation of cells with different concentrations of bupivacaine, s-ketamine, morphine and dexamethasone for 1 h.MAIN OUTCOME MEASURES:Fraction of Annexin V positive and Annexin V and propidium iodide double positive cells after 1 h of incubation with tested drug measured by flow cytometry.RESULTS:Both morphine (0.1 to 10 μmol l) and dexamethasone (10 to 1000 μmol/l) failed to induce cytotoxicity after 1 h of exposure. The previously reported chondrotoxicity of bupivacaine (10 to 500 μmol l or 2.8 to 140 μg ml) was confirmed by a concentration-dependent increased staining with Annexin V and propidium iodide. Exposure to S-ketamine (10 to 500 μmol l) induced a significant late apoptotic and necrotic cell fraction at 10 μmol l or 2.4 μg ml. Concentrations of 100 and 500 μmol l induced a significant increase in early apoptotic cells.CONCLUSION:Morphine and dexamethasone showed no cytotoxic effects in our study and might thus be better alternatives to the clinically frequently applied bupivacaine. S-ketamine induced an intensive dose-dependent cytotoxic effect and should probably be avoided for intra-articular injection.