Background and Objectives: Operative blood loss is strongly correlated with morbidity and mortality in surgery. Various hemostatic agents are used to reduce bleeding in cardiothoracic procedures. We report our experience with a plant-based microporous polysaccharide hemostatic powder (Starsil® Hemostat, Hemostat Medical GmbH, Velen, Germany). Materials and Methods: Data were collected retrospectively from 65 patients who underwent cardiac surgery at our institution from January 2012 to January 2015 with (n = 42) or without (n = 23; control group) the use of the hemostat powder. Primary endpoints were safety (e.g., laboratory parameters, adverse events, and infection parameters) and time to hemostasis when the hemostat powder was used. Other endpoints included operation time, hospitalization, quantity of the hemostat powder applied, and length of stay in the intensive care unit. Results: The 65 patients (49 male:16 female) analyzed in the study underwent 65 cardiothoracic procedures, including off-pump coronary artery bypass grafts (n = 25), on-pump coronary artery bypass grafts (n = 6), valve procedures (n = 6), valve procedures in combination with bypass grafts (n = 7), and others (n = 21). The application of the hemostat powder did not increase adverse events. The laboratory parameters did not exceed the expected range after heart surgery in both groups. The hemostat powder had no significant impact on the laboratory parameters compared to the control group. Blood control was sufficient and was rated by surgeons from good to very good on a visual analog scale (VAS) from 1 (very bad) to 10 (very good) [VAS = 8.3 ± 1.2]. Intraoperative hemostasis was possible in nearly all patients. The hemostat powder led to satisfactory bleeding control within 2 min in 88% of cases. Five patients needed a second 5 g unit of the hemostat powder. Conclusions: The observed parameters between groups did not differ significantly. Therefore, the use of Starsil® Hemostat in cardiothoracic surgery is safe and effective bleeding control was achieved.

Abstract Background Patients requiring coronary artery bypass grafting (CABG) are often loaded with antithrombotic drugs (AT) and are at an increased risk for perioperative bleeding complications. Active AT removal by a hemoadsorption cartridge integrated in the cardiopulmonary bypass circuit is increasingly used in this setting to reduce bleeding, and herein we describe the extension of this application in patients on AT undergoing off-pump coronary artery bypass (OPCAB). Methods Ten patients (80% male; mean age: 67.4 ± 9.2years) were treated with ticagrelor (eight patients), rivaroxaban and ticagrelor (one patient), and rivaroxaban (one patient) prior to OPCAB surgery. AT’s were discontinued one day before surgery in nine patients and on the day of surgery in one patient, and all patients were also on aspirin. The cohort mean EuroSCORE-II was 2.9 ± 1.5%. A hemoadsorption cartridge was integrated into a dialysis device (n=4) or a stand-alone apheresis pump (n=6) periprocedural, for a treatment time of 145 ± 33 min. Outcome measures included bleeding according to Bleeding Academic Research Consortium (BARC)-4 and 24-hour chest-tube-drainage (CTD). Results Mean operation time was 184 ± 35 min. All patients received a left internal thoracic artery with a mean of 2.3 ± 0.9 total grafts. One patient had a BARC-4 bleeding event and there were no surgical re-explorations for bleeding. Mean 24-hours CTD was 680 ± 307mL. During follow-up of 19.5 ± 17.0 months, none of the patients died or required further reinterventions. No device-related adverse events were reported. Conclusions Hemoadsorption via a stand-alone apheresis pump during OPCAB surgery was feasible and safe. This innovative and new approach showed favorable bleeding rates in patients on antithrombotic drugs requiring bypass surgery.

Objectives: Postoperative atrial fibrillation (POAF) is a frequent complication following cardiac surgery. This study examined the safety and efficacy of the new DefiPaceTM system consisting of two bi-atrial temporary pacing and cardioversion electrodes, a ventricular electrode and the DefiPaceTM device (combined external pacemaker and cardioverter) for low-energy atrial cardioversion. Methods: The temporary electrodes were placed on the left and right atrium during open heart surgery. Pacing thresholds and sensing were measured up to the 6th postoperative day. The satisfactory handling of the electrodes was measured with a visual analog scale (VAS) 1–10, with 10 being the best and 1 being the lowest. In case of POAF, R-wave synchronous low-energy shocks (0.5–10 J) were applied for cardioversion. Results: Temporary electrodes were implanted in 29 patients (age 65.6 ± 10.4 years; 21 males, 14 OPCAB, 15 on-pump cardiac operations). Left or right atrial pacing thresholds ranged from 1.9 ± 1.3 V/ms to 5.0 ± 3.3 V/ms and P-wave sensing from 0.9 ± 0.6 mV to 1.5 ± 0.7 mV. VAS for handling of electrodes: implantation 7.1 ± 0.8 and removal 8.4 ± 1.0. POAF was observed in four patients. Two patients had successful atrial cardioversion with 3.5 J and 4.5 J. One patient converted spontaneously, and one patient remained in PAOF. There were no device-related adverse events. Conclusions: The DefiPaceTM system can be used safely in patients undergoing cardiac surgery.

Background and Objectives: The hemoadsorption device CytoSorb® (CytoSorbents Inc., Princeton, NJ, USA) has been shown to efficiently remove ticagrelor from whole blood in vitro. A promising clinical experience was made with the integration of the hemoadsorption cartridge on the cardiopulmonary bypass (CPB) circuit during cardiac surgery to reduce adverse events. Materials and Methods: In this report, we describe a novel approach using a new apheresis platform, PUR-01 (Nikkisio Co., Ltd., Tokyo, Japan), which was used as the extracorporeal circuit where CytoSorb® could be installed for the removal of ticagrelor during off-pump coronary artery bypass (OPCAB) procedures. Results: In a 74-year-old male (index case) with coronary artery disease and dual antiplatelet therapy, hemoadsorption was initiated with a skin incision for OPCAB surgery and was continued for 221 min to eliminate ticagrelor. The blood volume that had circulated through the CytoSorb® was 39.04 L in total. Thus far, this treatment strategy has been used in four cases with CHD and DAPT who needed OPCAB surgery. The intraoperative and postoperative courses were uneventful in all patients. No device-related adverse events occurred. Conclusions: The combination of the PUR-01 apheresis pump and hemoadsorption with the CytoSorb® column during OPCAB procedures appears to be safe and effective in eliminating antiplatelet drugs.

CytoSorb hemoadsorption (CytoSorbents Inc, Monmouth Junction, NJ) was performed shortly before an urgent off-pump coronary artery bypass operation in a 58-year-old man at high risk of bleeding as a result of treatment of coronary artery disease with ticagrelor and treatment of atrial fibrillation with rivaroxaban. The patient experienced dissection of the left anterior descending artery during a percutaneous coronary intervention. Preoperatively, CytoSorb hemoadsorption was applied to eliminate the coagulative active medications. His intraoperative and postoperative courses were uneventful, with adequate bleeding control. This case highlights a promising approach for managing antiplatelet drugs and anticoagulant agents such as ticagrelor and rivaroxaban before off-pump coronary artery bypass.

Background: Lack of autologous graft material restricts the ability to treat patients requiring coronary artery bypass surgery (CABG). An off the shelf tissue engineered small diameter vascular graft is the holy grail of cardiovascular surgery. Methods: Allograft saphenous veins were harvested from organ donors, cryopreserved, deendothelialized and then seeded with autologous endothelial cells prior to implantation during coronary artery bypass surgery. All patients treated were followed-up until death and angiographic results were collected. Grafts were explanted during autopsy and immunohistochemistry was performed. Results: Twelve patients received 15 engineered grafts. Mean patient survival was 9.1 +/- 1.8 years. Six month graft patency was 80 (95% CI: 59-100) and 9 month graft patency was 50 (95% CI: 27-93) - graft patency detected up to 32 months after surgery. Immunohistochemistry in grafts explanted showed a presence of CD31 and CD68 positive cells in the luminal region of the vessel walls and layers of Collagen Type I in the abluminal vessel walls. Conclusions: Our small diameter tissue engineered vascular graft shows openness up to 32 months after implantation. Immunohistochemistry suggests that monocyte activation may lead to vessel remodeling with thickening of the vessel wall. Research should concentrate on a manipulation of remodeling processes.

PURPOSE:The HEARTSTRING Proximal Seal System is used to avoid aortic clamping to insert the intraaortic balloon pump (IABP) in the ascending aorta or the aortic arch. This technique is used when calcification or atheroma prevents side clamping of the ascending aorta or the aortic arch.DESCRIPTION:A vein graft or a small-caliber vascular prosthesis for the later insertion of the IABP is sewn to the ascending aorta or the aortic arch using the HEARTSTRING Proximal Seal System.EVALUATION:In our department, this technique is applied whenever insertion of the IABP is not feasible via the femoral arteries.CONCLUSION:The technique allows the safe insertion of the IABP via the ascending aorta or the aortic arch.

OBJECTIVE:This study aimed to investigate the influence of the flavonoid oxerutin (Venoruton®, Novartis, Basel, Switzerland) on endothelial cell apoptosis and transendothelial migration of peripheral blood mononuclear cells and to elucidate the potential mechanisms affecting these processes.METHODS:Human endothelial cells were treated with Venoruton to assess the potential effect on apoptosis and on the transendothelial migration process. Endothelial nitric oxide synthase and inducible nitric oxide synthase expression in endothelial cell after Venoruton treatment as well as reactive oxygen species levels were analyzed.RESULTS:Low-dose Venoruton shows a protective effect on endothelial cells and inhibits transendothelial migration of peripheral blood mononuclear cells through an endothelial monolayer, but high-dose Venoruton inversely elevated transendothelial migration of peripheral blood mononuclear cells. Meanwhile, a dose-dependent action of Venoruton on endothelial cell apoptosis could be observed. Endothelial nitric oxide synthase and inducible nitric oxide synthase expression were gradually increased in endothelial cells with increasing Venoruton dosage. In addition, reactive oxygen species were significantly reduced by 0.1 mM and 0.5 mM Venoruton and elevated after high dose treatment.CONCLUSION:These data suggest that the increased transendothelial migration of peripheral blood mononuclear cells is related to the excessive activation of the nitric oxide-axis and subsequent relaxation of the endothelial cells.

OBJECTIVES:Osteosynthetic closure of the chest after median sternotomy is usually performed with steel wires. We describe, for the first time, a case series in which titanium hooks were implanted from the sternal surface in patients who required secondary or additional stabilization. In comparison to the classic wires, the diameters of the hooks are approximately three times bigger and therefore reduce the risk of cutting through the bones. Additionally, there is no need to dissect retrosternal adhesions, which may reduce the risk of injuring mediastinal tissues. METHODS:The hooks are shaped like fishing hooks and can be inserted parasternally into the intercostal spaces. They can be pulled to the contralateral side of the sternum by the attached wires and then intertwined with a second hook. RESULTS:In 13 patients, the system was used to provide additional stabilization, while in two patients the hooks were implanted for exclusive stabilization of sternal fractures. In all cases but one, the implantation was able to eliminate the sternal problems. No infections, necrosis or bleeding of neighbouring tissues occurred. One patient developed chronic sternal infection, which necessitated explantation of the hooks. CONCLUSIONS:This sternal closure system using titanium hooks inserted parasternally is an effective alternative to conventional techniques and may increase stability of the breastbone and reduce the risk of injury to retrosternal tissues.

Suture injury of the circumflex coronary artery (CX) and infarction are considered a major complication after a mitral valve operation [1Virmani R. Chun P.K. Parker J. McAllister Jr, H.A. Suture obliteration of the circumflex coronary artery in three patients undergoing mitral valve operation Role of left dominant or codominant coronary artery.J Thorac Cardiovasc Surg. 1982; 84: 773-778PubMed Google Scholar]. Herein we present a procedure that illustrates the opportunity of direct intraoperative coronary angiography in the hand of the cardiac surgeon for immediate reaction without time delay and myocardial ischemia.A 62-year-old woman with symptomatic aortic and mitral valve stenosis was referred to our institution for a double-valve operation. Coronary angiography revealed no lesions. Through a median sternotomy, the massively calcified mitral valve was replaced with a mechanical prosthesis. Due to the intensely calcified annulus, deep “U” sutures had to be made to avoid paravalvular leakage. In regard to a possible injury of the CX and after replacement of both valves, a direct intraoperative coronary angiography with a digital C arm (BV Pulsera [Philips BV Medical Systems, Eindhoven, The Netherlands]) was performed through the still open aortic root. The contrast medium was delivered through the cardioplegic solution catheters under visual control to the coronary ostia, as previously described [2Kilian E. Beiras-Fernandez A. Bauerfeind D. Reichart B. Lamm P. Intraoperative coronary angiography in the management of patients with acute aortic dissection and endocarditis.J Thorac Cardiovasc Surg. 2008; 136: 792-793Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar] This showed a proximal occlusion of the CX (Fig 1; LAD = left anterior descending artery); therefore, we anastomosed a venous bypass to the first marginal branch. The further surgical procedure and hospital stay was uneventful. The patient's latest echocardiogram showed good ventricular function. Electrocardiograph and laboratory results showed no signs of ischemia.The herewith presented technique demonstrates the potency of the intraoperative coronary angiography during heart operations showing the possibility of immediate reaction to complications without major delay and extended ischemia. Suture injury of the circumflex coronary artery (CX) and infarction are considered a major complication after a mitral valve operation [1Virmani R. Chun P.K. Parker J. McAllister Jr, H.A. Suture obliteration of the circumflex coronary artery in three patients undergoing mitral valve operation Role of left dominant or codominant coronary artery.J Thorac Cardiovasc Surg. 1982; 84: 773-778PubMed Google Scholar]. Herein we present a procedure that illustrates the opportunity of direct intraoperative coronary angiography in the hand of the cardiac surgeon for immediate reaction without time delay and myocardial ischemia. A 62-year-old woman with symptomatic aortic and mitral valve stenosis was referred to our institution for a double-valve operation. Coronary angiography revealed no lesions. Through a median sternotomy, the massively calcified mitral valve was replaced with a mechanical prosthesis. Due to the intensely calcified annulus, deep “U” sutures had to be made to avoid paravalvular leakage. In regard to a possible injury of the CX and after replacement of both valves, a direct intraoperative coronary angiography with a digital C arm (BV Pulsera [Philips BV Medical Systems, Eindhoven, The Netherlands]) was performed through the still open aortic root. The contrast medium was delivered through the cardioplegic solution catheters under visual control to the coronary ostia, as previously described [2Kilian E. Beiras-Fernandez A. Bauerfeind D. Reichart B. Lamm P. Intraoperative coronary angiography in the management of patients with acute aortic dissection and endocarditis.J Thorac Cardiovasc Surg. 2008; 136: 792-793Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar] This showed a proximal occlusion of the CX (Fig 1; LAD = left anterior descending artery); therefore, we anastomosed a venous bypass to the first marginal branch. The further surgical procedure and hospital stay was uneventful. The patient's latest echocardiogram showed good ventricular function. Electrocardiograph and laboratory results showed no signs of ischemia. The herewith presented technique demonstrates the potency of the intraoperative coronary angiography during heart operations showing the possibility of immediate reaction to complications without major delay and extended ischemia.

The number of percutaneous coronary interventions (PCI) prior to coronary artery bypass grafting (CABG) increased drastically during the last decade. Patients are referred for CABG with more severe coronary pathology, which may influence postoperative outcome. Outcomes of 200 CABG patients, collected consecutively in an observational study, were compared (mean follow-up: 5 years). Group A (n = 100, mean age 63 years, 20 women) had prior PCI before CABG, and group B (n = 100, mean age 66, 20 women) underwent primary CABG. In group A, the mean number of administered stents was 2. Statistically significant results were obtained for the following preoperative criteria: previous myocardial infarction: 54 vs 34 (P = 0.007), distribution of CAD (P < 0.0001), unstable angina: 27 vs 5 (P < 0.0001). For intraoperative data, the total number of established bypasses was 2.43 +/- 1.08 vs 2.08 +/- 1.08 (P = 0.017), with the number of arterial bypass grafts being: 1.26 +/- 0.82 vs 1.07 +/- 0.54 (P = 0.006). Regarding the postoperative course, significant results could be demonstrated for: adrenaline dosage (0.83 vs 0.41 mg/h; [p is not significant (ns)]) administered in 67 group A vs 47 group B patients (P = 0.006), and noradrenaline dosage (0.82 vs 0.87 mg/h; ns) administered in 46 group A vs 63 group B patients (P = 0.023), CK/troponine I (P = 0.002; P < 0.001), postoperative resuscitation (6 vs 0; P = 0.029), intra aortic balloon pump 12 vs 1 (P = 0.003), and 30-day mortality (9% in group A vs 1% in group B; P = 0.018). Clopidogrel was administered in 35% of patients with prior PCI and in 19% of patients without prior PCI (P = 0.016). Patients with prior PCI presented for CABG with more severe CAD. Morbidity, mortality and reoperation rate during mid term were significantly higher in patients with prior PCI.

BACKGROUND:Since 2002 MI and stroke, not cancer, are leading causes of death in women. We studied 30-days and 1 year mortality of 3441 patients undergoing coronary artery bypass grafting (CABG) operations in our institution performed either conventionally or off pump (OPCAB). Our objective was to investigate the gender-related mortality in both groups.PATIENTS AND METHODS:Between 2004 and 2008, 3441 patients (733 women, 2708 men) underwent CABG. 252 women and 854 men were operated using OPCAB, 481 women and 1854 men using extracorporeal circulation (ECC). Medical data was prospectively entered and retrospectively reviewed. 30-days and one year mortality rates were analyzed with Kaplan-Meier estimates and Cox proportional hazards models. Linear and logistic regression models were used to test gender differences.RESULTS:a) 30-day mortality using ECC: 5.2% in women vs. 2.5% in men (p = 0.001). One year ECC mortality: 8.7% in women vs. 4.8% in men (p = 0.0008). b) OPCAB: 30-days and 1 year mortality in women measured 1.7%. Mortality in men was 2.1% after 30 days and 3.7% after one year c) gender specific mortality: 30 days mortality in women was 1.7% using OPCAB and 5.2% using ECC (p = 0.002), one year mortality in women was 1.7% using OPCAB vs. 8.7% using ECC (p = 0.0004). In men, 30-days mortality in OPCAB was 2.1%, one year mortality was 3.7%; using ECC early and late mortality was 2.5% and 4.8%.CONCLUSIONS:Female gender is a strong independent predictor and risk factor of increased early and midterm postoperative mortality rates when ECC is used. OPCAB significantly reduces early and midterm postoperative mortality in women and may therefore be proposed as the preferred revascularization technique in female patients.

OBJECTIVE:To evaluate the feasibility and outcomes of protocol-driven noninvasive mechanical ventilation in patients with acute respiratory failure (ARF) after cardiac surgery.METHODS:From 2001 to 2004, a total of 2428 cardiac surgery patients admitted to our intensive care unit were observed. After exclusion of patients who received tracheostomy or were discharged while still on mechanical ventilation, 2261 patients with spontaneous breathing were further evaluated for ARF. Patients diagnosed with ARF were treated with intermittent noninvasive mechanical ventilation (NIV) if possible. Risk factors for the development of postoperative ARF as well as outcomes in patients with and without ARF were analyzed.RESULTS:In 2261 spontaneously breathing postoperative cardiac surgical patients after primarily successful extubation, 799 patients (35%) were diagnosed with ARF. Fifty-six patients (7%) did not tolerate NIV treatment. In 743 patients (33%) intermittent NIV was performed. In patients with ARF, ejection fraction was lower, combined cardiac surgical procedures were more frequent, postoperative mechanical ventilation time was longer, and the severity of illness score (SAPS II) was higher (P < .05). The duration of catecholamine support was longer, and the transfusion rate was higher in the NIV group (P < .05); however, mortality did not differ between patients with ARF treated by NIV and patients without ARF.CONCLUSION:Our study demonstrates the feasibility of NIV in patients after cardiac surgery. These results might suggest that NIV should be considered as first-line ventilatory support in ARF after cardiac surgery. A large randomized trial is warranted to confirm these findings.

Background. Since 2002 MI and stroke, not cancer, are leading causes of death in women. We studied 30-days and 1 year mortality of 3441 patients undergoing coronary artery bypass grafting (CABG) operations in our institution performed either conventionally or off pump (OPCAB). Gender-related mortality in both groups was determined. Patients and Methods. Between 2004 and 2008, 3441 patients (733 women, 2708 men) underwent CABG. 252 women and 854 men were operated using OPCAB, 481 women and 1854 men using extracorporeal circulation (ECC). Medical data was prospectively entered and retrospectively reviewed. 30-days and one year mortality rates were analyzed with Kaplan-Meier estimates and Cox proportional hazards models. Linear and logistic regression models were used to test gender differences. Results. a) 30-day mortality using ECC: 5.2 % in women vs. 2.5% in men (p=0.001). One year ECC mortality: 8.7% in women vs. 4.8% in men (p=0.0008). b) OPCAB: 30-days and 1 year mortality in women measured 1.7%. Mortality in men was 2.1% after 30 days and 3.7% after one year c) gender specific mortality: 30 days mortality in women was 1.7% using OPCAB and 5.2% using ECC (p=0.002), one year mortality in women was 1.7% using OPCAB vs. 8.7% using ECC (p=0.0004). In men, 30-days mortality in OPCAB was 2.1%, one year mortality was 3.7%; using ECC early and late mortality was 2.5% and 4.8%. Conclusions. Female gender is a strong independent predictor and risk factor of increased early and midterm postoperative mortality rates when ECC is used. OPCAB significantly reduces early and midterm postoperative mortality in women and may therefore be proposed as the preferred revascularization technique in female patients.

The HEARTSTRING Proximal Seal System (Guidant Corp, Santa Clara, CA) is used to avoid aortic clamping while the proximal anastomoses are sewn. To protect surgeons from spurting blood while the device is used, we use a see through plastic sheet to cover the area being operated on. This modified technique is applied whenever the system is used and allows the safe use of the device even in high-risk patients with hepatitis or human immunodeficiency virus.

For implantable cardioverter defibrillator a 10 J safety margin between the defibrillation threshold (DFT) and the maximum output of the device is intended. In complex cases, the additional placement of a subcutaneous array lead is a common strategy for lowering the DFT. We report the successful use of transvenous coil electrodes as single element subcutaneous array leads in order to lower the DFT.

We thank Drs Messori and Trippoli for their interest. They have critically examined our statistical methods regarding early deaths (30 days) following cardiac transplantation with and without left ventricular assist devices (LVADs). From a purely statistical argument, they are correct: as the LVAD group had shorter follow-up, 30 days provided a greater influence in 6 years versus 19 years of follow-up. Upon reanalysis with the "traditional presentation," of the 294 no-LVAD subjects, 23 (8%) died early.