Introduction People with aortic/prosthetic valve endocarditis are a high-risk cohort of patients who present a challenge for all medically involved disciplines and who can be treated by various surgical techniques. Methods We analyzed the results of treatment of root endocarditis with Medtronic Freestyle® in full-root technique over 19 years (1999-2018) and compared them against treatment with other tissue valves. Comparison was made with propensity score matching, using the nearest neighbor method. Various tests were performed as suited for adequate analyses. Results Fifty-four patients in the Medtronic Freestyle group (FS group) were matched against 54 complex root endocarditis patients treated with other tissue valves (Tissue group). Hospital mortality was 9/54 (16.7%) in the FS group vs. 14/54 (25.6%) in the Tissue group (P=0.24). Cox regression performed for early results demonstrated coronary heart disease (P=0.004, odds ratio 2.3), among others, influencing early mortality. Recurrent infection was low (1.8% for FS and Tissue patients) and freedom from reoperation was 97.2% at a total of 367 patient-years of follow-up (median of 2.7 years). Conclusion The stentless xenograft is a viable alternative for treatment of valve/root/prosthetic endocarditis, demonstrating a low rate of reinfection. The design of the bioroot allows for complex reconstructive procedures at the outflow tract and the annular level with at an acceptable operative risk. Endocarditis patients can be treated excluding infective tissue from the bloodstream, possibly with benefits, concerning bacteremia and recurrent infection. Furthermore, the use of the stentless bioroot offers varying treatment options in case of future valve degeneration.

Abstract Aims To report the largest single-center experience in surgical aortic valve replacement (SAVR) using the Enable sutureless bioprosthesis concerning the clinical outcome and hemodynamic behavior. Material and methods From April 2010 to May 2017, a total of 432 patients (36.3% of them women) received the Enable sutureless prosthesis for aortic valve stenosis, regurgitation, and/or endocarditis. The endpoints were overall survival after operation for 30 days and adverse events. Results No intraoperative complications occurred; intraoperative mortality was 0%. The 30-day mortality rate was 3.5% overall and 0.9% for isolated procedure. No valve-related deaths were observed. There was a need for prosthesis replacement during the early postoperative period in eight patients (1.9%): seven patients (1.6%) had a significant paravalvular leak and one patient (0.2%) developed early postoperative endocarditis. The maximum and mean pressure gradients across the prosthesis were 19.2 ± 7.1 mmHg and 11.1 ± 4.6 mmHg, respectively. A permanent pacemaker was necessary in 6.5% of the patients. Conclusions The Enable sutureless prosthesis showed a reliable clinical outcome with low perioperative mortality and morbidity. The hemodynamic performance was satisfactory. Our data confirmed the safety of SAVR using the Enable bioprosthesis. However, a higher rate of pacemaker implantation (6.5%) has to be mentioned.

BACKGROUNDS:Aortic valve and prosthetic valve endocarditis present a challenging subgroup of patients at high risk. We analyzed our experience using the Medtronic Freestyle in full root technique for the treatment of these cases over 18-year time period.METHODS:We investigated the endocarditis subgroup from our cohort of 971 patients and compared results against other valve types with propensity score matching implementing nearest neighbor method. T-test, χ2 test, logistic regression, and Cox regression were performed.RESULTS:Fifty-four patients from the Freestyle group (FS) were matched against 54 patients from a cohort of 376 aortic valve/root endocarditis patients treated by other valve types (non-FS). Hospital mortality was 9/54 (16.7%) in the FS vs 13/54 (24.1%) in the non-FS group (P = .33). Variables age (P = .003) and renal impairment (P = .026) had an impact on mortality according to Cox regression analysis for early results. Variables with significant risk for long-term mortality included postoperative renal impairment (P = .0001) and multiorgan failure (P = .0001). Recurrent infection was low (1.8% for FS and 3.7% for non-FS group), and freedom from reoperation was 97.2%. Use of the Medtronic Freestyle was no significant risk factor for long-term mortality.CONCLUSION:The Freestyle stentless xenograft is a viable alternative for treatment of valve/root and prosthetic endocarditis. In our experience, it showed good postoperative performance with low rate of reinfection while having an acceptable operative risk-profile for this high-risk cohort.

PURPOSE: We report the first real- life experience with the AvalusTM valve (Medtronic, Minneapolis, MN, USA), a novel stented, pericardial bioprosthesis designed for aortic valve replacement. Recent trials demonstrated excellent hemodynamic performance and favorable valve- related outcomes. The study was approved by our institutional review board. METHODS: From November 2017 to September 2018 the AvalusTM prosthesis was implanted in 57 patients (male:72% / median age: 75; range 59-84 years / median Euroscore II: 3,2; range 1- 20,1) due to severe aortic valve pathology. Concomitant procedures included coronary artery bypass grafting (29,8%), mitral valve annuloplasty (7,0%), mitral valve replacement (5,2%) tricuspid valve annuloplasty (5,2%%), atrial septal defect closure (1,7%) and aortic surgery (1,7%). 24,5% of the procedures were performed through a limited surgical access. RESULTS: Median aortic cross-clamp time for isolated valve replacement was 58 minutes (range 40-88 minutes) and for combined procedures 99 minutes (range: 82- 167 minutes). Mean (DPmean) and maximal (DPmax) transvalvular gradients at discharge (median postoperative day 9; range 8-34 days) were low (median DPmean: 8mmHg; range 3-19 mmHg / median DPmax 16 mmHg; range 6-29 mmHg). In contrast to other pericardial valves a tiny central leakage was documented in only 1 patient. Thromboembolic or hemorrhagic events and cases of prosthesis endocarditis were not documented. Overall 30 days mortality was 0%. CONCLUSIONS: In our experience the Avalus bioprosthesis demonstrated excellent hemodynamic results, easy implantability and a good safety profile. CLINICAL IMPLICATIONS: Due to it's remarkably low transvalvular gradients long- term durability could prove to be superior compared to other stented bioprostheses.

PURPOSE: Experience with Left Ventricular Assist Device (LVAD) therapy in patients with non- compaction cardiomyopathy (LVNC) is limited. Recently an aggressive surgical approach consisting of radical trabecular debridement and deeper positioning of the inflow cannula in the left ventricular cavity was proposed as a way to reduce thrombogenic surface area and anticipate interaction of trabeculae with the LVAD inflow. However, by just performing selective excision of prominent myocardial trabeculae protruding in the left ventricular cavity without radically debriding the left ventricular wall operative procedure can be kept simple and adverse events can just as well be avoided METHODS: A HeartMate 3 device was implanted in a 41 years old male patient with a known LVNC. Instead of radically debriding left ventricular wall prior to placement of the inflow cannula, prominent myocardial trabeculae protruding in the left ventricular cavity were identified and then sharply excised at their endomyocardial origin so as to reduce the size of blood flow stagnation area and avoid potential interaction of trabecular remnants with the inflow cannula. RESULTS: Postoperative course was uneventful. Following hospital discharge, patient has had to date (572 days after surgery) experienced no adverse events and pump function is unimpeded. CONCLUSIONS: Identification and selective excision of prominent myocardial trabeculae can be a way to prevent adverse events without, as recently proposed having to radically debride left ventricular myocardium. CLINICAL IMPLICATIONS: In cases of LVNC excision of prominent myocardial trabeculae during LVAD implantation can facilitate event-free long-term survival.

Ameloblastome sind seltene langsam wachsende, lokal aggressive odontogene Tumore, die von den schmelzbildenden, epithelialen Zellen (Ameloblasten) der Zahnanlage ausgehen. Aufgrund der hohen Rezidivneigung stellen sie eine besondere Herausforderung für den behandelnden Chirurgen dar.

BACKGROUND:Gastrointestinal complications following on-pump cardiac surgery are orphan but serious risk factors for postoperative morbidity and mortality. We aimed to assess incidence, perioperative risk factors, treatment modalities and outcomes.MATERIAL AND METHODS:A university medical center audit comprised 4883 consecutive patients (median age 69 [interquartile range IQR 60-76] years, 33% female, median logistic EuroScore 5 [IQR 3-11]) undergoing all types of cardiac surgery including surgery on the thoracic aorta; patients undergoing repair of congenital heart disease, implantation of assist devices or cardiac transplantation were excluded. Coronary artery disease was the leading indication for on-pump cardiac surgery (60%), patients undergoing cardiac surgery under urgency or emergency setting were included in analysis. We identified a total of 142 patients with gastrointestinal complications. To identify intra- and postoperative predictors for gastrointestinal complications, we applied a 1:1 propensity score matching procedure based on a logistic regression model.RESULTS:Overall, 30-day mortality for the entire cohort was 5.4%; the incidence of gastrointestinal complications was 2.9% and median time to complication 8 days (IQR 4-12). Acute pancreatitis (n = 41), paralytic ileus (n = 14) and acute cholecystitis (n = 18) were the leading pathologies. Mesenteric ischemia and gastrointestinal bleeding accounted for 16 vs. 18 cases, respectively. While 72 patients (51%) could be managed conservatively, 27 patients required endoscopic/radiological (19%) or surgical intervention (43/142 patients, 30%); overall 30-day mortality was 12.1% (p<0.001). Propensity score matching identified prolonged skin-to-skin times (p = 0.026; Odds Ratio OR 1.003, 95% Confidence Interval CI 1.000-1.007) and extended on-pump periods (p = 0.010; OR 1.006, 95%CI 1.001-1.011) as significant perioperative risk factors.COMMENT:Prolonged skin-to-skin times and extended on-pump periods are important perioperative risk factors regardless of preoperative risk factors.

Due to the declining instances of organ donation, total artificial heart (TAH) therapy is of increasing importance for the management of end-stage biventricular heart failure. We introduce the currently most important established and novel TAH systems (SynCardia, CARMAT, ReinHeart, BiVACOR), report clinical outcomes and discuss technical requirements for the successful implementation of TAH therapy as an alternative to cardiac transplantation.

Our aim was to analyse the hospital outcome for the worldwide largest series of stentless bioroot xenografts (Medtronic Freestyle) as full root replacement in a single centre over a period of 18 years. Retrospective data analysis was performed for the entire cohort of patients undergoing aortic root surgery with the Medtronic Freestyle valve prosthesis. Logistic regression analysis was performed to analyse predictors of in-hospital mortality. 971 patients underwent aortic full root replacement with the Medtronic Freestyle valve in the period from 1999–2017, with an average age of 68.8 ± 10.3y and gender distribution of 608:363 (male:female). Concomitant surgery was performed in 693 patients (71.4%). In-hospital all-comers mortality was 9.8% (95 patients), with the respective highest risk profiles including dissections (6.4%), endocarditis (5.6%) and re-do procedures (12.5%). In-hospital mortality for elective patients was 7.6% while isolated aortic root replacement demonstrated a mortality of 3.6%. Logistic regression analysis demonstrated age (OR 1.05, p = 0.005), dissection (OR 5.78, p < 0.001) and concomitant bypass surgery (OR 2.68, p < 0.001) as preoperative risk factors for the entire cohort. Postoperative analysis demonstrated myocardial infarction (OR 48.6, p < 0.001) and acute kidney injury (OR 20.2, p < 0.001) to be independent risk factors influencing mortality. This analysis presents a work-through of all patients with stentless bioroot treatment without positive selection in a high-volume clinical center with the largest experience world-wide for this form of complex surgery. Isolated aortic root replacement could be performed at acceptable operative risk for this technically-challenging procedure.

Abstract Background Aorto-esophageal fistula is a rare but life-threatening event evolving spontaneously or—more often—following therapeutic interventions at the esophagus or the aorta. Especially in presence of long-standing inflammation preceding the formation of the fistula, acute surgical closure of the aortic leakage is all but impossible and interdisciplinary treatment is mandatory. Methods Review of cases of aorto-esophageal fistula within the last 12 years. Results In our collective of patients undergoing esophagectomy since 2005 (N = 445) we observed 7 cases (1,5%) of aorto-esophageal fistula. In one case the fistula had developed spontaneously following aspergillosis, one patient had had aortic stenting 29 years before, another one had developed anastomotic dehiscence following intrathoracic esophago-jejunostomy and in 4 cases esophageal stenting had been done. 5 patients presented with slight to dramatic hematemesis which in 2 instances needed endoscopic intervention, 2 had no bleeding. Preoperative angio-CT confirmed aorto-esophageal fistula in 3 cases who underwent aortic stenting prior to the surgical intervention, in 3 patients the fistula was found intraoperatively (aortic replacement N = 1; suture followed by stenting N = 1; operation stopped; aortic stenting, operation the following day). All patients recovered from surgery. In one case inflammation had caused partial necrosis of the aortic wall causing fatal bleeding during operation. Retrospectively, the lesion of the aortic wall could be identified on CT in all but one patient. Conclusion By interdisciplinary management, involving preoperative stenting or aortic graft implantation in cases not amenable to stenting, patients with aorto-esophageal fistula can be saved and may undergo elective esophageal surgery. Disclosure All authors have declared no conflicts of interest.

Objectives: Direct Flow Medical® (DF)-prosthesis has been introduced for TAVR procedures in patients with aortic stenosis. In aortic insufficiency however, this fully retrievable and repositionable prosthesis has been used in limited cases only. Its flexible frame might promote secure fixation by adapting smoothly to the aortic anulus. Aim of this study was to evaluate, if implantation into a non-calcified native anulus throughout conventional aortic valve replacement is feasible and to prove firm positioning throughout a pharmacologically induced hyperdynamic state.