Introduction and importance:Multiple sclerosis is known to be associated with both sympathetic and parasympathetic cardiovascular autonomic dysregulation. Thus, patients with multiple sclerosis comorbidity represent a potentially challenging patient population in cardiac surgery, especially in on-pump operations. Despite this, very little is known about the hemodynamics during cardiopulmonary bypass and the optimal perfusion strategy for patients with multiple sclerosis undergoing cardiac operations.Case presentation:In this report, the authors describe a patient with relapsing-remitting multiple sclerosis, who underwent successful triple valve operation for aortic and mitral stenosis and tricuspid valve insufficiency. Distinct blood pressure variations in form of temporary pressure dips were noted during total cardiopulmonary bypass time as well as during the reperfusion period.Clinical discussion:Pressure variations were not attributable to surgical, pharmacological or perfusion-related manoeuvres. Thus, they most likely represent symptoms of cardiovascular autonomic dysregulation manifesting during cardiopulmonary bypass. In this patient, blood pressure variations terminated spontaneously and remained within an acceptable range without external correction.Conclusions:When treating patients with multiple sclerosis comorbidity, the potential pressure variability due to cardiovascular autonomic dysregulation should be taken into consideration to avoid increased blood pressure volatility due to overcorrection or undercorrection during cardiopulmonary bypass.

Background Severe acute respiratory distress syndrome (ARDS) due to Coronavirus Disease-19 (COVID-19) is associated with high mortality. Although survival on mechanical circulatory support has improved, determinants for better prognosis are still unclear. Here, we report on the outcome of our patient population with the need for mechanical circulatory support due to severe COVID-19 (sCOVID-19) induced ARDS. Methods All patients treated with extracorporeal membrane oxygenation (ECMO) for severe ARDS due to sCOVID-19 were analysed. Patients > 18 years of age at the time of initiation of ECMO were included. Pre-existing comorbidities, complications during ECMO implantation, and ECMO runtime were reviewed. The latency to intubation, proning, tracheotomy, and ECMO implantation was analysed. Furthermore, the survival and non-survival population were compared to determine factors in favour of a better outcome. Results In total, 85 patients were treated with veno-venous membrane oxygenation (vv-ECMO) for severe ARDS in our medical centre. The patient population was predominantly male (83.5%) with a mean patient age of 54.9 years. A history of cardiovascular disease ( p = .01), smoking ( p < .05), need for vasopressor- ( p < .05), and renal replacement therapy ( p < .001) was associated with a worse prognosis. Overall survival was 50%. The survival population was significantly younger ( p = .004), had a significantly higher body weight ( p = .02) and body mass index (BMI) ( p = .01). Furthermore, survival was significantly better when vv-ECMO was initiated within 48 h after admission ( p < .001). Conclusions Pre-existing cardiovascular disease, higher age, history of nicotine abuse, and development of renal failure are associated with poor outcome. Early start of vv-ECMO therapy may lead to better survival in sCOVID-19 patients, although complications during ECMO therapy are associated with a worse prognosis.

Introduction: Acute aortic dissection Stanford type A (AADA) is a surgical emergency associated with high morbidity and mortality. Although surgical management has improved, the optimal therapy is a matter of debate. Different surgical strategies have been proposed for patients under 60 years old. This paper evaluates the postoperative outcome and the need for secondary aortic operation after a limited surgical approach (proximal arch replacement) vs. extended arch repair.Methods: Between January 2000 and January 2018, 530 patients received surgical treatment for AADA at our hospital; 182 were under 60 years old and were enrolled in this study - Group A (n=68), limited arch repair (proximal arch replacement), and group B (n=114), extended arch repair (> proximal arch replacement).Results: More pericardial tamponade (P=0.005) and preoperative mechanical resuscitation (P=0.014) were seen in Group A. More need for renal replacement therapy (P=0.047) was seen in the full arch group. Mechanical ventilation time (P=0.022) and intensive care unit stay (P<0.001) were shorter in the limited repair group. Thirty-day mortality was comparable (P=0.117). New onset of postoperative stroke was comparable (Group A four patients [5.9%] vs. Group B 15 patients [13.2%]; P=0.120). Long-term follow-up did not differ significantly for secondary aortic surgery.Conclusion: Even though young patients received only limited arch repair, the outcome was comparable. Full-arch replacement was not beneficial in the long-time follow-up. A limited approach is justified in the cohort of young AADA patients. Exemptions, like known Marfan syndrome and the presence of an intimal tear in the arch, should be considered.

BACKGROUND:Infective endocarditis (IE) poses a significant health risk, especially in patients with prosthetic heart valves. Despite advances in treatment, mortality rates remain high. This study aims to investigate the antibacterial properties of a copper titanium dioxide (4× Cu-TiO2) coating on cardiovascular implants against Staphylococcus aureus, a common causative agent of IE.METHODS:Titanium oxide carriers functionalized with copper ions were employed as an antibacterial coating for heart and vascular prostheses. The coating's antibacterial efficacy was assessed using S. aureus ATCC 29213. Microscopic evaluations were conducted on both biological and artificial materials. Antibacterial activity was qualitatively assessed via a modified disc diffusion method and quantitatively measured through colony counts in NaCl suspensions.RESULTS:The coating process was successfully applied to all tested cardiovascular prosthetic materials. Qualitative assessments of antibacterial effectiveness revealed an absence of bacterial growth in the area directly beneath the coated valve. Quantitative evaluations showed a significant reduction in bacterial colonization on coated mechanical valves, with 2.95 × 104 CFU per valve, compared to 1.91 × 105 CFU in control valves.CONCLUSIONS:The 4× Cu-TiO2 coating demonstrated promising antibacterial properties against S. aureus, suggesting its potential as an effective strategy for reducing the risk of bacterial colonization of cardiovascular implants. Further studies are needed to assess the longevity of the coating and its efficacy against other pathogens.

(1) Background: Implant-associated bacterial infections are usually hard to treat conservatively due to the resistance and tolerance of the pathogens to conventional antimicrobial therapy. Bacterial colonization of vascular grafts may lead to life-threatening conditions such as sepsis. The objective of this study is to evaluate whether conventional antibiotics and bacteriophages can reliably prevent the bacterial colonization of vascular grafts. (2) Methods: Gram-positive and Gram-negative bacterial infections were simulated on samples of woven PET gelatin-impregnated grafts using Staphylococcus aureus and Escherichia coli strains, respectively. The ability to prevent colonization was evaluated for a mixture of broad-spectrum antibiotics, for strictly lytic species-specific bacteriophage strains, and for a combination of both. All the antimicrobial agents were conventionally tested in order to prove the sensitivity of the used bacterial strains. Furthermore, the substances were used in a liquid form or in combination with a fibrin glue. (3) Results: Despite their strictly lytic nature, the application of bacteriophages alone was not enough to protect the graft samples from both bacteria. The singular application of antibiotics, both with and without fibrin glue, showed a protective effect against S. aureus (0 CFU/cm2), but was not sufficient against E. coli without fibrin glue (M = 7.18 × 104 CFU/cm2). In contrast, the application of a combination of antibiotics and phages showed complete eradication of both bacteria after a single inoculation. The fibrin glue hydrogel provided an increased protection against repetitive exposure to S. aureus (p = 0.05). (4) Conclusions: The application of antibacterial combinations of antibiotics and bacteriophages is an effective approach to the prevention of bacteria-induced vascular graft infections in clinical settings.

Secondary infections of skin grafts pose a continuous problem in burn patients, very often leading to loss of transplanted skin grafts and making multiple surgical revisions necessary. We present a case report about persisting Pseudomonas aeruginosa infection in burn patients with known diabetes. The burn wounds in lower extremities required repeated debridements, multiple skin grafting attempts and finally an application of the dermal scaffold NovoSorb BTM. With these measures, we managed to undertake a successful reconstruction of infected burn defects and pre-vent an amputation. We concluded that the NovoSorb BTM could be seen as an additional promising tool in a burn surgery armamentarium. In cases where radical surgical wound decontamination is not possible without risking the loss of the limb, the application of NovoSorb BTM over a contaminated field can win extra time for topical infection treatment and additionally provide an excellent skin grafting ground.

OBJECTIVES:The wearable cardioverter defibrillator (WCD) is an established, safe, effective solution, protecting patients at risk of sudden cardiac death. We specifically investigated WCD use in cardiac surgery patients since data for this patient group are rare. METHODS:Retrospective data analysis in 10 German cardiac surgery centres was performed. Cardiac surgery patients with left ventricular ejection fraction (LVEF) ≤35% or after implantable cardioverter defibrillator (ICD) explantation who received WCD between 2010 and 2020 were assessed using LifeVest Network data. RESULTS:A total of 1168 patients with a median age of 66 years [interquartile range (IQR) 57-73] were enrolled; 87% were male. Clinical indications included coronary artery bypass grafting (43%), valve surgery (16%), combined coronary artery bypass graft/valve surgery (15%), ICD explantation (24%) and miscellaneous (2%). The median wear time of WCD was 23.4 h/day (IQR 21.7-23.8). A total of 106 patients (9.1%) exhibited ventricular tachycardia. A total of 93.2% of episodes occurred within the first 3 months. Eighteen patients (1.5%) received 26 adequate shocks. The inadequate shock rate was low (8 patients, 0.7%). LVEF improved from a median of 28% (IQR 22-32%) before WCD prescription to 35% (IQR 28-42%) during follow-up. Excluding ICD explant patients, 37% of patients received an ICD. CONCLUSIONS:The risk of sudden cardiac death is substantial within the first 3 months after cardiac surgery. Patients were protected effectively by WCD. Due to significant LVEF improvement, the majority did not require ICD implantation after WCD use. Compliance was high despite sternotomy. This multicentre experience confirms existing data regarding effectiveness, safety and compliance. Therefore, WCD should be considered in cardiac surgery patients with severely reduced LVEF.

Strictly lytic or virulent bacteriophages against Staphylococcus aureus belong to order Caudovirales and comprise predominantly two genera: Kayvirus and Rosenblumvirus. Representatives of both taxonomic groups are well known as safe and viable antibacterial agents. Phages of the genus Kayvirus show usually a broad host range activity against clinical isolates of S. aureus. Nevertheless continuous isolation of new phages against these bacteria is required in order to provide sufficient activity for therapy of biofilms or to prevent phage inactivation by neutralizing antibodies. In the present study, we describe an approach for isolation of lytic bacteriophages of the genus Kayvirus by mitomycin C induction of clinical isolates of S. aureus. Our findings suggest the clinical isolates of S. aureus a reach source for lytic bacteriophages. However taking into account the inducibility of the Kayvirus representatives it have to be evaluated a presence of further unknown life cycles for these bacteriophages such as pseudolysogeny.

(1) Objective: Bacterial resistance to conventional antibiotic therapy is an increasingly significant worldwide challenge to human health. The objective is to evaluate whether bacteriophage therapy could complement or be a viable alternative to conventional antibiotic therapy in critical cases of bacterial infection related to cardiothoracic surgery. (2) Methods: Since September 2015, eight patients with multi-drug resistant or especially recalcitrant Staphylococcus aureus, Enterococcus faecium, Pseudomonas aeruginosa, Klebsiella pneumoniae, and Escherichia coli infections were treated with bacteriophage preparations as a therapy of last resort according to Article 37 of the Declaration of Helsinki. Patients had infections associated with immunosuppression after organ transplantation or had infections of vascular grafts, implanted medical devices, and surgical wounds. Individualized phage preparations were administered locally, orally, or via inhalation for different durations depending on the case. All patients remained on conventional antibiotics during bacteriophage treatment. (3) Results: Patients ranged in age from 13 to 66 years old (average 48.5 ± 16.7) with seven males and one female. Eradication of target bacteria was reached in seven of eight patients. No severe adverse side effects were observed. (4) Conclusions: Phage therapy can effectively treat bacterial infections related to cardiothoracic surgery when conventional antibiotic therapy fails.

Background: Infection of vascular grafts is a life-threatening complication in cardiovascular surgical procedures. This experimental study tested the efficacy and possible harmful effects of daptomycin pre-treatment in vivo in prevention of vascular graft infection caused by Staphylococcus aureus. Methods: Polyethylene terephthalate (PET) patches (5 × 7 mm) were sewn on the infra-renal abdominal aorta of 32 New Zealand White rabbits. Before implantation, patches either were pre-treated for 15 min with daptomycin in one group (n = 13) or left untreated in the other group (n = 13) before contamination with 100 mcL bacterial solution (1 × 1010 colony-forming units [CFU] per mL). Six animals with uninfected patches without (n = 3) or with (n = 3) daptomycin pre-treatment served as controls. On postoperative day seven, all patches were explanted, washed with phosphate buffered saline, and sonicated to release viable adherent bacteria. The CFUs were quantified and aortic tissues were histologically examined. In addition, bacterial adherence on the patches was analyzed using scanning electron microscopy (SEM). Results: In the daptomycin pre-treatment group, significantly reduced numbers of CFUs on the patches were observed, compared with non-pre-treated patches (3.21 × 102 ± 1.02 × 103 mL-1 vs. 5.18 × 105 ± 1.05 × 106 mL-1; p < 0.001). Peri-vascular abscesses were visible in all rabbits with S. aureus infected patches, whereas no signs of inflammation were found in the daptomycin pre-treatment group or the control groups. Conclusions: Daptomycin showed excellent in vivo antibacterial activity against vascular graft infection caused by S. aureus, compared with non-pre-treated grafts, resulting in a significant reduction in bacterial infection and prevention of abscess formation. No harmful effects of the antibiotic pre-treatment could be observed.

Fibrin glue has been used clinically for decades in a wide variety of surgical specialties and is now being investigated as a medium for local, prolonged drug delivery. Effective local delivery of antibacterial substances is important perioperatively in patients with implanted medical devices or postoperatively for deep wounds. However, prolonged local application of antibiotics is often not possible or simply inadequate. Biofilm formation and antibiotic resistance are also major obstacles to antibacterial therapy. In this paper we test the biocompatibility of bacteriophages incorporated within fibrin glue, track the release of bacteriophages from fibrin scaffolds, and measure the antibacterial activity of released bacteriophages. Fibrin glue polymerized in the presence of the PA5 bacteriophage released high titers of bacteriophages during 11 days of incubation in liquid medium. Released PA5 bacteriophages were effective in killing Pseudomonas aeruginosa PA01. Overall, our results show that fibrin glue can be used for sustained delivery of bacteriophages and this strategy holds promise for many antibacterial applications.

This case report presents an accidental detection of a post-infarct ventricular septal defect (VSD) by a patient undergoing emergent coronary artery bypass grafting and left ventricular aneurysm resection. Both myocardial lesions were repaired simultaneously through the left ventricular aneurysm. The patient’s postoperative course was uneventful. This case shows the importance of intraoperative transesophageal echocardiography, as well as inspection of the interventricular septum, in an emergency setting to detect possible infarct VSDs.

Background Minimally invasive mitral valve surgery (MIMVS) is superior to classical mitral valve surgery via a sternotomy regarding wound healing and postoperative pain. It is however a more challenging procedure. Patients' preference is leading clearly toward minimally invasive approaches, and surgeons are driven by upcoming new technologies in interventional procedures such as the MitraClip. Especially in re-do cases, the access via right mini-thoracotomy, as previously non-operated situs, is a possible advantage over a re-sternotomy. We therefore retrospectively analyzed our result regarding MIMVS in re-do cases at our institute. Methods From January 2011 and June 2016, 33 operations were MIMVS re-do procedures. Mean age was 60 years (16 years), and 51% were male. Results Sixty-one percent were elective cases, 29% were urgent cases, and 9% were emergency operations. Operation times, cardiopulmonary bypass (CPB) times, and clamp times were 235 minutes (+/- 51 min), 149 minutes (+/- 42 min), and 62 minutes (+/- 45min), respectively. Mitral valve repair and replacement was performed in 24% ( n =8) and 76% ( n =25), respectively. Overall in-hospital mortality, apoplexy, and re-operation rates (all for bleeding) were 0% ( n =0), 3% ( n =1), and 9% ( n =3). New onset of dialysis was required in two (6%) patients. Two (6%) patients developed superficial wound infection. Overall intensive care unit (ICU) and hospital stay was 3 days (+/- 4 days) and 15 days (+/- 7 days), respectively. Conclusion MIMVS for re-do cases can be performed with minimal mortality and morbidity and therefore represents a safe alternative to conventional mitral valve surgery in cardiac re-do operations. However, postoperative morbidity is highly dependent on preoperative patient status.

Fibromuscular dysplasia is a non-inflammatory, non-atherosclerotic vascular disease, occurring predominantly in younger females. A histologically heterogeneous group of fibroplasia without an inflammatory component causes arterial narrowing. It affects mostly one or both renal arteries, cervicocranial or visceral arteries, leading to hypertension, renal failure/renal infarction or stroke/transient ischaemic attack. We present the case of a young female patient with abdominal aortic coarctation, history of acute renal failure, and critical hypertension due to pseudo-occlusion of both renal arteries. We performed renal artery revascularization specifically by using the Riolan anastomosis as feeding vessel.

Objective Pleural tubes after coronary artery bypass graft (CABG) surgery usually cause pain resulting interalia in an impact of postoperative breathing. Therefore, the influence of intrapleural lidocaine application through special double-lumen chest tubes with respect to pain relief and lung function was investigated and compared with placebo. Methods In this study, 40 patients who underwent CABG got intrapleural injection either with 2% lidocaine ( n =20) or placebo (0.9% saline solution) ( n =20) on the first 2 days after surgery. Pain was measured by pain intensity numeric rating scale (NRS) (0=no pain; 10=the most intense pain) and lung function by portable spirometer. Results On the first postoperative day (POD1), mean pain reduction was NRS 1.9 for the lidocaine group with an improvement of the forced expiratory volume in 1 second (FEV1) of 0.51 L. Similar results were shown on the second postoperative day (POD2) with a decreased pain level of mean NRS 1.65 and an FEV1 improvement of 0.26 L. In comparison, results of the placebo group showed no significant pain reduction, neither on the POD1 (NRS 0.35; p =0.429) nor on the POD2 (NRS 0.55; p =0.159). Also, there was no significant influence of FEV1 after placebo on the POD1 (FEV1=0.048L; p =0.70) or on the POD2 (FEV1=0.0135L; p =0.925). Conclusion Intrapleural application of lidocaine is a safe and feasible method to reduce drainage-related pain and improving lung function after CABG.