BACKGROUND:Vasoplegic syndrome is associated with high mortality. Methylene blue (MB) is a guanylate cyclase inhibitor that ameliorates this re-distributive type of shock. This study aims to investigate the outcome in patients who received MB early postoperatively. METHODS:2753 patients who underwent cardiac surgery utilizing cardiopulmonary bypass at our institution in a time interval of two years were identified. The incidence of vasoplegic syndrome was 7.2% (n = 200). Pharmacy records identified 84 patients (group 1, MB group) who received methylene blue and 116 patients (group 2, Control group) who didn't receive the drug. This single-center retrospective cohort study's primary outcome was in-hospital mortality. Secondary outcomes were postoperative hemodialysis, serum lactate levels at 24 h postoperatively, and intensive care unit stay length in days. RESULTS:MB patients have a shorter ICU stay as compared to the control group (9 ± 8 days vs. 16 ± 6.9; p-value <.001). In the control group, postoperative hemodialysis was higher (20% in the MB group and 40% in the control group; p-value <.05). At 24 h post-op, the methylene blue group had reduced serum lactate levels (1.8 ± 1.2 vs. 4 ± 1.8 in the control group; p-value <.001). The methylene blue group had a decreased 24-hour norepinephrine dose (1.5 ± 1.2 vs. 2.8 ± 2 in the control group; p-value <.05). In-hospital mortality was not significantly different between the two groups (38% in the MB group vs. 43% in the control group). CONCLUSION:Early postoperative administration of methylene blue in patients with vasoplegic syndrome shortens intensive care unit stay and contributes to less end-organ damage.

Right ventricular (RV) failure is associated with significant morbidity and mortality, with in-hospital mortality rates estimated to be as high as 70-75%. The RV failure can occur after cardiac surgery or isolated in certain situations, such as acute myocardial infarction, pulmonary embolism, left ventricular assist device implantation or after heart transplantation. Drug treatment includes fine tuning of the volume status and administration of inotropic agents, vasopressors and pulmonary vasodilators. Selected patients with persistent RV failure may benefit from mechanical circulatory support. Percutaneous and surgical mechanical support systems are increasingly being used. Systems for isolated RV support include percutaneous options, such as micro-axial flow pumps and extracorporeal centrifugal flow support devices as well as surgical options with RV support devices and arteriovenous extracorporeal membrane oxygenation. This review discusses the indications, patient selection, treatment strategies and outcomes of mechanical circulatory support for RV failure.

Das Versagen des rechten Ventrikels (RV) geht mit erheblicher Morbidität und Mortalität einher, wobei die Sterblichkeitsraten im Krankenhaus auf bis zu 70–75

Purpose: Right-side heart failure (RSHF) jeopardizes the Left ventricular assist device implantation device (LVAD) short and long-term outcomes. The model for end-stage liver disease (MELD) score is an effective means of evaluating liver dysfunction. This study aims to investigate the predictive utility of preoperative MELD on the post-LVAD impanation outcomes.

Intraoperative antithrombotic drug removal by haemoadsorption is a novel strategy to reduce perioperative bleeding in patients on antithrombotic drugs undergoing cardiac surgery. The international STAR registry reports real-world clinical outcomes associated with this application. All patients underwent cardiac surgery before completing the recommended washout period. The haemoadsorption device was incorporated into the cardiopulmonary bypass (CPB) circuit. Patients on P2Y12 inhibitors comprised group 1, and patients on direct-acting oral anticoagulants (DOAC) group 2. Outcome measurements included bleeding events according to standardised definitions and 24-hour chest-tube-drainage (CTD). 165 patients were included from 8 institutions in Austria, Germany, Sweden, and the UK. Group 1 included 114 patients (62.9 ± 11.6years, 81

Patient-tailored silicone plug for HeartMate 3™ left ventricular assist device explantation in two successive males proceeded successfully. Given medical therapeutic advancements, FDA-approved plug systems designed by LVAD manufacturers themselves will be necessary for the near future to provide a safe and simple device explantation alternative that fulfills all regulatory standards.

Malignant cardiac tumors of the heart are extremely rare and may present tremendous diagnostic and therapeutic challenges. These tumors are able to infiltrate the heart and metastasize systemically. Early detection is often elusive as the clinical presentation is highly variable, posing significant diagnostic and therapeutic difficulties. Despite a multidisciplinary approach, the prognosis for patients with malignant cardiac tumors remains guarded. Early diagnosis and a multidisciplinary approach involving cardiac surgeons, oncologists and critical care specialists are crucial in the management of this disease. Further research is needed to better understand the pathomechanisms of tumor-related complications and to develop effective treatment strategies to improve patient outcomes. The rare case of a 78-year-old woman with left atrial tumor requiring emergency surgery for acutely developing mitral valve obstruction is presented. Pathology confirmed an undifferentiated pleomorphic sarcoma. This patient tragically did not survive, highlighting the difficulties of managing such a rare and deceptive heart disease.

Introduction Pump thrombosis is a major complication of CF LVAD therapy, affecting approximately 5% of HVAD (HeartWare) patients. Case Report We report a 76-year-old male with stage D congestive heart failure and three years of HVAD destination therapy experiencing a low-flow alert. Echocardiography revealed insufficient LV unloading. A lowered average flow of 1.98 L/min was observed, and power consumption remained at 3.1 Watts at 2700 rpm. No changes in the acoustic signal and an absence of hemolysis evidence in the serum workup. CT angiography showed LV dilatation with no outflow cannula thrombosis or stenosis and was negative for pulmonary embolism.Therefore, a pre-pump thrombus was suspected. For destination therapy, patients' pump exchange is the gold standard for managing LVAD thrombosis. As the HVAD was not available at this moment, pump exchange with the HeartMate 3 (HM3) appeared not practicable in this sick patient. Hence, a retrograde thrombus washout maneuver was performed while the patient was awake and spontaneously breathing: With vasopressors, mean blood pressure was raised to 100 mmHg, and ventricular contractility was improved with intravenous adrenaline. The pump was turned off for 10 seconds while manually squeezing carotid arteries in Trendelenburg's position to avoid cerebral thromboembolism. After restarting the pump, the parameters reverted to normal, with a flow of 4.2 L/min and a power of 4.1 Watts at 2700 rpm.The patient had no perfusion or neurological abnormalities during or after the procedure. Summary Pre-pump, intra-pump, and post-pump flow obstructions can occur as HVAD flow obstructions (Figure 1). Pump exchange remains the gold standard for managing LVAD thrombosis, but the invasiveness of the surgery disqualifies some patients: In particular, the exchange of an HVAD pump in the current era involves not only medical and surgical obstacles but also a logistical dilemma, as Medtronic terminated the distribution and sale of the HVAD system on June 3, 2021.

Key Clinical Message Complex presentations of MCS patients may necessitate a multidisciplinary approach involving HF cardiologists, CT surgeons, advanced cardiac imagers, and interventional cardiologists in order to define the optimal management strategy. Abstract Left ventricle assist devices (LVADs) provide life‐sustaining treatment for patients with terminal heart failure, but their intricacy allows for complications. One complication is LVAD outflow graft obstruction due to the graft's intraluminal thrombus or extraluminal compression. It may be treated endovascularly with stenting. We report an endovascular stenting of an outflow tract in HVAD™ (HeartWare Inc.) due to a pseudoaneurysm causing compression and kinking stenosis.

Background: The CytoSorb® is used to adsorb low and medium molecular weight hydrophobic substances to counteract increasing organ dysfunction by reducing inflammatory mediators, metabolites and proteins, thus potentially positively influencing the recovery process. The aim of this study is to evaluate the effects of the CytoSorb® on the selected organ functions heart, kidneys and liver in patients undergoing implantation of a Medtronic HeartwareTM-HVADTM-LVAD. Methods: A monocentric retrospective observational study was performed. After evaluation of the in-clinic database, 19 patients underwent LVAD implantation at the Department of Cardiac Surgery, Erlangen University Hospital, from Nov 1, 2019 to Jan 1, 2021. Of these, 6 patients received postoperative therapy with CytoSorb® (CytoSorbentsTM Inc) and formed group “A” of this study. A control group “non-A” without CytoSorb® was matched to group “A” regarding: age, sex, BMI, EuroSCORE II, duration of surgery, defined pre- and postoperative laboratory parameters and outcome. The use of cytokine adsorber in group “A” was analyzed. Its effects on heart, kidneys and liver were assessed by defined laboratory parameters (myoglobin, CK, creatinine, urea, BUN, total bilirubin and AST) and at defined time points. The outcome of patients in group “A” was assessed by 30-day mortality. Results: The group comparison showed: group “A” had a higher arithmetic mean risk profile in the EuroSCORE II (m(A) 10.3% vs. m(non-A) 7.2%), a higher BMI (m(A) 32.26 kg/m2 vs. m(non-A) 26.75 kg/m2), and a longer duration of surgery (m(A) 176 min. vs. m(non-A) 145 min.). Preoperative laboratory parameters: higher values in group “A” for creatinine, urea, BUN, total bilirubin, and AST; lower values in group “A” for myoglobin and CK. 24 hours postoperatively: a statistically significant difference for total bilirubin (95% CI: 0.48 to 7.42; p = 0.03), at a fixed significance level of α < 0.05, no significant differences for myoglobin, CK, creatinine, urea and AST for both groups. Analysis of group “A” in the first 24 h after starting therapy: the serum levels of myoglobin, creatinine, urea, total bilirubin and AST did not increase further on arithmetic average or began to decrease moderately. For CK, this effect was seen with a 24 h time lag. A statistically significant decrease for urea was observed over the entire 72 h period (95% CI: - 35.097 to - 7.073; p = 0.006), and the use of the adsorber correlated with a decrease in the value by an average of 21.08 points. Outcome group “A” : 3 patients in group “A” with late mortality > 30 days. Conclusion: The CytoSorb® therapy in group “A” did not lead to any further increase in the arithmetic mean values of the laboratory values examined over the entire time course of the analysis. A rebound in serum levels was observed for myoglobin and total bilirubin after termination of adsorber therapy. Persistent or further increasing organ dysfunction of heart and liver could be considered as causal.

The ultimate goal in the treatment of end-stage heart failure is the recovery of cardiac function following mechanical assistance of the left ventricle. The HVAD™ pump (HeartWare Inc.) left ventricular assist device (LVAD) can be explanted without resternotomy. This article demonstrates that the use of a custom-made mechanical plug (manufactured by INNOVO Solutions GmbH), which can be inserted into the LVAD's sewing ring, is feasible. This mechanical plug explicitly designed for device explantation is a viable alternative to the current standard of care. This article adopts a less invasive technique to explant the pump. The following case illustrates this technique.

The success of the left ventricular assist device (LVAD) as a treatment for terminal left-side heart failure is still restrained by some severe complications associated with mechanical circulatory support. Pump thrombus still affects many patients. It is associated with high morbidity and mortality. The therapeutic options include augmentation of anticoagulation and antiplatelet medication, intravenous or catheter-guided thrombolysis, and pump exchange. Heart transplantation would be a desirable option in this population, but unfortunately, it is only theoretical given the increasing number of LVAD implants and decreasing number of organ donors. A retrograde washout maneuver may be a treatment option in prepump thrombosis in selected patients. Therefore, the decision should be made on an individual basis after balancing the risks and benefits of different treatment approaches. In this context, we report a case of retrograde washout of prepump thrombus in a patient who has been on HeartWare™ support for more than 3 years, with a successful bailout strategy.

Background: Intra-aortic balloon pump (IABP) is a controversially discussed option to treat patients with heart failure. The overall impact and hereby also the prophylactic implantation of an IABP have decreased in recent years, but is still part of surgical practice. Therefore, the aim of this study was to investigate prophylactic implantation of an IABP on the outcome of high-risk patients from a single center.

Background. Prior studies have shown that cytomegalovirus (CMV) infection is a risk factor for the development of cardiac allograft vasculopathy (CAV) and is associated with reduced long-term survival after heart transplantation (HTx). The aim of this International Society for Heart and Lung Transplantation Transplant Registry study was to compare posttransplant survival in different CMV donor:recipient serologic combinations. Methods. We performed a retrospective cohort study, using the International Society for Heart and Lung Transplantation Thoracic Transplant Registry, on 15 885 adult primary heart transplant recipients with known CMV serologic status between July 2004 and June 2014. Posttransplant survival and risk of developing CAV were compared across 4 groups: CMV-seronegative recipients (R–) receiving CMV-positive grafts (D+), intermediate-risk patients (D+R+ and D–R+), and low-risk patients (D–R–). Results. Baseline characteristics (donor/recipient age, body mass index, recipient serum creatinine, blood group, donor cause of death, recipient diagnosis, and ischemic time) were mostly balanced between the groups. Kaplan-Meier survival analyses over a follow-up of 10 y revealed significantly worse survival for both D+ groups as compared to the CMV low-risk group (D+R+: 56.61% [95% confidence interval, 53.94-59.41] versus D–R–: 63.09% [59.74-66.64] P < 0.01 and D+R–: 57.69% [56.03-59.39] versus D–R–; P < 0.001), whereas recipient seropositivity alone was not associated with reduced survival (D–R+ versus D–R– P = 0.178). The risk of developing CAV after HTx was not significantly increased in D+ as compared to D– groups. Conclusions. In a large contemporary cohort, CMV status at the time of HTx was not associated with CAV development. However, there was a significant association between donor CMV seropositivity and reduced short- and long-term survival after HTx. Approaches to mitigate the impact of CMV on posttransplant survival are needed.

INTRODUCTION:The Frozen Elephant Trunk technique is a well-established treatment for aortic dissections (Stanford Type A) involving the aortic arch and descending aorta. The Thoraflex™ Hybrid prosthesis (Vascutek Ltd.), consisting of a proximal flexible conduit and a distal self-expanding covered stent, has consistently shown positive results in the treatment of this condition.CASE DESCRIPTION:The following is a description of such a staged reconstruction using the Thoraflex™ Hybrid Ante-Flo™ device, performed in a patient previously diagnosed with Loeys-Dietz Syndrome. After clamping the aorta proximally, an incision was taken at the distal end of the stent. Here, the distal end of the new prosthesis was inserted into the true lumen of the descending aorta and the stent was deployed. Following this, a bypass was established via the left atrium, and blood was returned to the lower body using the perfusion arm of the prosthesis with the proximal part of the descending aorta clamped. The collar of the prosthesis was sutured proximally to the aorta near the inlying previous stent. Air was removed via the perfusion arm of the prosthesis, which was then oversewn.DISCUSSION:To date, hybrid prostheses have only been used on the proximal aorta in patients with aortic aneurysms and aortic dissections (Stanford Type A).CONCLUSION:Using the described technique, it is possible to reconstruct the aortic anatomy using the available prostheses with accuracy and minimal complications.

OBJECTIVES: Myocardial recovery allows for left ventricular assist device (LVAD) explantations after long-term support. Several surgical approaches, including interventional decommissioning, off-pump explantation using a custom-made plug and complete LVAD removal through redo sternotomy, have been described. We present the results from an evaluation of the long-term follow-up of patients who received a titanium sintered plug after LVAD explantation. METHODS: We performed a retrospective, European, multicentre analysis of patients who received a titanium sintered plug to seal the apical fixation ring after LVAD explantation. Data were collected from a questionnaire that included demographics, procedural details and follow-up information. RESULTS: Out of 54 contacted centres in 12 countries (n = 179 patients), a total of 68 patients were successfully included in the study. The median follow-up was 34 months (interquartile range: 17-58.5 months); 57 (84%) patients had >1-year follow-up. At the time of the last follow-up, 55 (81%) patients were alive, with a Kaplan-Meier 1-year survival of 90.1% (95% confidence interval: 84.0-98.1%) and a 5-year survival of 80.0% (95% confidence interval: 68.4-92.9%). One patient (1.5%) developed a plug infection originating from an infected part of the incorporated driveline and, after complete removal, is currently in good condition. No postoperative stroke has been reported after plug implantation. CONCLUSIONS: In this European multicentre study, the use of a custom-made titanium plug to close the apical fixation ring after LVAD explantation resulted in a low incidence of plug-related complications. With the volume of patients undergoing LVAD explantations after myocardial recovery increasing, the plug has evolved as a simple alternative to more invasive device explantation procedures or decommissioning with a high risk for infection of the remaining system or stroke.

Objectives: Endomyocardial biopsy (EMB) is considered as the gold standard method to identify rejection after heart transplantation. However, it`s routine use beyond the first year after transplantation remains controversial. A previous study revealed a higher rate of ACR in the long term in calcineurin inhibitor (CNI) free patients. The aim of the present study was to determine the incidence of late graft rejection in all routine surveillance biopsies and cost-analysis in long term follow up after heart transplantation.

Abstract Background-Reconstruction of the thoracoabdominal aorta after dissection (Stanford Type A with extension into descending aorta) has limited surgical options. Described here is a novel technique for the staged surgical repair of the thoracoabdominal aorta after reconstruction of the ascending aorta with aortic arch using a hybrid prosthesis. Case presentation- The thoracoabdominal aorta is accessed via a lateral thoracotomy. After a left-left bypass to perfuse the descending aorta, the proximal end of the prosthesis is anastomosed to the proximal aorta and distal end of the new prosthesis is then inserted into the true lumen of the descending aorta and the stent is deployed. Conclusion-Using this technique, operative time is reduced with accurate reconstructions of the anatomy.