Die Echokardiographie ist ein zentrales Element in der Diagnostik von Patienten in der Notfall- und Intensivmedizin. Die transösophageale Echokardiographie (TEE) kann im Gegensatz zur transthorakalen Echokardiographie (TTE) unabhängig von Patientenhabitus, Beatmung und Lagerung durchgeführt werden und liefert dadurch eine konstant gute Bildqualität. Relevante Pathologien und reversible Ursachen eines Herz-Kreislauf-Stillstands (z. B. Lungenarterienembolie, Perikardtamponade) können schnell diagnostiziert und damit einer Behandlung zugänglich werden. Zusätzlich bleiben im Rahmen der kardiopulmonalen Reanimation ununterbrochene Thoraxkompressionen während der Diagnostik mittels TEE gewährleistet und es kommt zu keiner diagnostikbedingten Verlängerung der „no-flow-time“ (Unterbrechung der Thoraxkompressionen während der kardiopulmonalen Reanimation). Einige Studien beschreiben auch den Nutzen der TEE zur Termination der Reanimationsmaßnahmen bei ausbleibender mechanischer Herzaktivität. Ein weiteres Anwendungsgebiet der TEE stellt die Implantation und (Re‑)Positionierung der Kanülierung von Kreislaufunterstützungssystemen (z. B. „extracorporeal life support“, ECLS) dar. Zusammengefasst ist die TEE ein sicheres, schnell erlernbares und der TTE in einigen Aspekten überlegenes Verfahren zur Diagnostik von Schockraumpatienten. Die TEE kann bei ausreichender Expertise zu einem diagnostischen Instrument im Rahmen der kardiopulmonalen Reanimation werden. Die Anwendungsgebiete, Vorteile und potenzielle Risiken der TEE im Rahmen der Versorgung kritisch kranker Schockraumpatienten, einschließlich Reanimationssituationen, sollen dargestellt werden.

The number of patients waiting for heart transplantation (HTX) is increasing. Thus, identification of outcome-relevant factors is crucial. This study aimed to identify perioperative factors associated with days alive and out of hospital (DAOH)—a patient-centered outcome to quantify life impact—after HTX. This retrospective cohort study screened 187 patients who underwent HTX at university hospital Duesseldorf, Germany from September 2010 to December 2020. The primary endpoint was DAOH at 1 year. Risk factors for mortality after HTX were assessed in univariate analysis. Variables with significant association were entered into multivariable quantile regression. In total, 175 patients were included into analysis. Median DAOH at 1 year was 295 (223–322) days. In univariate analysis the following variables were associated with reduced DAOH: recipient or donor diabetes pre-HTX, renal replacement therapy (RRT), VA-ECMO therapy, recipient body mass index, recipient estimated glomerular filtration rate (eGFR) and postoperative duration of mechanical ventilation. After adjustment, mechanical ventilation, RRT, eGFR and recipient diabetes showed significant independent association with DAOH. This study identified risk factors associated with reduced DAOH at 1-year after HTX. These findings might complement existing data for outcome of patients undergoing HTX.

Thromboembolism is frequent in infective endocarditis (IE). However, the optimal antithrombotic regimen in IE is unknown. Staphylococcus aureus (SA) is the leading cause of IE. First studies emphasize increased platelet reactivity by SA. In this pilot study, we hypothesized that platelet reactivity is increased in patients with SA− IE, which could be abrogated by antiplatelet medication. We conducted a prospective, observatory, single-center cohort study in 114 patients with IE, with four cohorts: (1) SA coagulase positive IE without aspirin (ASA) medication, (2) coagulase negative IE without ASA, (3) SA coagulase positive IE with ASA, (4) coagulase negative IE with ASA. Platelet function was measured by Multiplate electrode aggregometry, blood clotting by ROTEM thromboelastometry. Bleeding events were assessed according to TIMI classification. In ASA-naïve patients, aggregation with ADP was increased with coag. pos. IE (coagulase negative: 39.47 ± 4.13 AUC vs. coagulase positive: 59.46 ± 8.19 AUC, p = 0.0219). This was abrogated with ASA medication (coagulase negative: 42.4 ± 4.67 AUC vs. coagulase positive: 45.11 ± 6.063 AUC p = 0.7824). Aspirin did not increase bleeding in SA positive patients. However, in SA negative patients with aspirin, red blood cell transfusions were enhanced. SA coagulase positive IE is associated with increased platelet reactivity. This could be abrogated by aspirin without increased bleeding risk. The results of this pilot study suggest that ASA might be beneficial in SA coagulase positive IE. This needs to be confirmed in clinical trials.

Abstract Aims Implantation of left ventricular assist devices (LVADs) as a bridge to transplant or as destination therapy is increasing. The selection of suitable patients and outcome assessment belong to the key challenges. Mortality has traditionally been a focus of research in this field, but literature on quality of life is very limited. This study aimed to identify perioperative factors influencing patients' life as measured by days alive and out of hospital (DAOH) in the first year after LVAD implantation. Methods and results This retrospective single‐centre cohort study screened 227 patients who underwent LVAD implantation at the University Hospital Duesseldorf, Germany, between 2010 and 2020. First, the influence of 10 prespecified variables on DAOH was investigated by univariate analysis. Second, multivariate quantile regression was conducted including all factors with significant influence on DAOH in the univariate model. Additionally, the impact of all variables on 1 year mortality was investigated using Kaplan–Meier curves to oppose DAOH and mortality. In total, 221 patients were included into analysis. As pre‐operative factors, chronic kidney disease (CKD), pre‐operative mechanical circulatory support (pMCS), and Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) stadium < 3 were associated with lower DAOH at 1 year [CKD: 280 (155–322) vs. 230 (0–219), P = 0.0286; pMCS: 294 (155–325) vs. 243 (0–293), P = 0.0004; INTERMACS 1: 218 (0–293) vs. INTERMACS 2: 264 (6–320) vs. INTERMACS 3: 299 (228–325) vs. INTERMACS 4: 313 (247–332), P ≤ 0.0001]. Intra‐operative additional implantation of a right ventricular assist device (RVAD) was also associated with lower DAOH [RVAD: 290 (160–325) vs. 174 (0–277), P ≤ 0.0001]. As post‐operative values that were associated with lower DAOH, dialysis and tracheotomy could be identified [dialysis: 300 (252–326) vs. 186 (0–300), P ≤ 0.0001; tracheotomy: 292 (139–325) vs. 168 (0–269), P ≤ 0.0001]. Multivariate analysis revealed that all of these factors besides pMCS were independently associated with DAOH. According to Kaplan–Meier analysis, only post‐operative dialysis was significantly associated with increased mortality at 1 year (survival: no dialysis 89.4% vs. dialysis 70.1%, hazard ratio: 0.56, 95% confidence interval: 0.33–0.94; P = 0.031). Conclusions The results of this study indicate that there can be a clear discrepancy between hard endpoints such as mortality and more patient‐centred outcomes reflecting life impact. DAOH may relevantly contribute to a more comprehensive selection process and outcome assessment in LVAD patients.

Background: The number of patients waiting for heart transplantation (HTX) is increasing. Optimizing the use of all available donor hearts is crucial. While mortality seems not to be affected by donor cardiopulmonary resuscitation (CPR), the impact of donor CPR on days alive and out of hospital (DAOH) is unclear. Methods: This retrospective study included adults who underwent HTX at the University Hospital Duesseldorf, Germany from 2010–2020. Main exposure was donor-CPR. Secondary exposure was the length of CPR. The primary endpoint was DAOH at one year. Results: A total of 187 patients were screened and 171 patients remained for statistical analysis. One-year mortality was 18.7%. The median DAOH at one year was 295 days (interquartile range 206–322 days). Forty-two patients (24.6%) received donor-CPR hearts. The median length of CPR was 15 (9–21) minutes. There was no significant difference in DAOH between patients with donor-CPR hearts versus patients with no-CPR hearts (CPR: 291 days (211–318 days) vs. no-CPR: 295 days (215–324 days); p = 0.619). Multivariate linear regression revealed that there was no association between length of CPR and DAOH (unstandardized coefficients B: −0.06, standard error: 0.81, 95% CI −1.65–1.53, p = 0.943). Conclusions: Donor CPR status and length of CPR are not associated with reduced DAOH at one year after HTX.

Acute kidney injury (AKI), requiring renal replacement therapy (RRT). is a serious complication after orthotopic heart transplantation (HTX). In patients with preexisting impaired renal function, postoperative AKI is unsurprising. However, even in patients with preserved renal function, AKI requiring RRT is frequent. Therefore, this study aimed to identify risk factors associated with postoperative AKI requiring RRT after HTX in this sub-cohort. This retrospective cohort study included patients ≥ 18 years of age with preserved renal function (defined as preoperative glomerular filtration rate ≥ 60 mL/min) who underwent HTX between 2010 and 2021. In total, 107 patients were included in the analysis (mean age 52 ± 12 years, 78.5% male, 45.8% AKI requiring RRT). Based on univariate logistic regression, use of extracorporeal membrane oxygenation, postoperative infection, levosimendan therapy, duration of norepinephrine (NE) therapy and maximum daily increase in tacrolimus plasma levels were chosen to be included into multivariate analysis. Duration of NE therapy and maximum daily increase in tacrolimus plasma levels remained as independent significant risk factors (NE: OR 1.01, 95%CI: 1.00–1.02, p = 0.005; increase in tacrolimus plasma level: OR 1.18, 95%CI: 1.01–1.37, p = 0.036). In conclusion, this study identified long NE therapy and maximum daily increase in tacrolimus plasma levels as risk factors for AKI requiring RRT in HTX patients with preserved renal function.

Abstract Aims Primary graft dysfunction (PGD) is a feared complication after heart transplantation (HTX). HTX patients frequently receive veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) until graft recovery. Long‐term mortality of patients weaned from VA‐ECMO after HTX is comparable with non‐ECMO patients. However, impact on quality of life is unknown. This study investigated days alive and out of hospital (DAOH) as patient‐centred outcome in HTX patients at 1 year after surgery. Methods and results This retrospective single‐centre cohort study included patients who underwent HTX at the University Hospital Düsseldorf, Germany, from 2010 to 2020. Main exposure was VA‐ECMO due to PGD. VA‐ECMO and non‐VA‐ECMO patients were compared regarding the primary endpoint DAOH at 1 year after HTX. Subgroup analysis for patients weaned from VA‐ECMO was performed. In total, 144 patients were included into analysis; 1 year mortality was significantly lower in non‐ECMO patients [non‐ECMO 14.3% (14/98) vs. VA‐ECMO 34.8% (16/46), adjusted hazard ratio: 0.32, 95% confidence interval: 0.15–0.74; P = 0.002]. Mortality did not differ significantly between patients weaned from VA‐ECMO and non‐ECMO patients [non‐ECMO 14.3% (14/98) vs. VA‐ECMO (weaned) 18.9% (7/37), adjusted hazard ratio: 0.72, 95% confidence interval: 0.27–1.90; P = 0.48]. DAOH were significantly higher in non‐ECMO patients compared with VA‐ECMO patients and patients weaned from VA‐ECMO [non‐ECMO vs. VA‐ECMO: median 310 (inter‐quartile range 277–327) days vs. 243 (0–288) days; P < 0.0001; non‐ECMO vs. VA‐ECMO (weaned): 310 (277–327) days vs. 253 (208–299) days; P < 0.0001]. These results were still significant after multivariable adjustment with forced entry of predefined covariables. Conclusions Despite similar survival rates, VA‐ECMO due to PGD has a relevant life impact as defined by DAOH in the first year after HTX. As a more patient‐centred endpoint, DAOH may contribute to a more comprehensive assessment of outcome in HTX patients.

Aim: The aim of this study was to evaluate the prognostic value of osteopontin (OPN) as a marker for left ventricular (LV) hypertrophy and its reversibility after surgical aortic valve replacement (SAVR). Patients & methods: Echocardiographic data and OPN plasma levels of 149 consecutive patients undergoing SAVR were obtained preoperatively and 3 months postoperatively. OPN was measured by Quantikine Human OPN immunoassay. Results: There was a significant correlation between higher OPN plasma levels and lower LV-mass regression. In patients receiving SAVR combined with coronary artery bypass grafting, high OPN plasma levels were also an indicator for eccentric hypertrophy phenotype. Conclusion: OPN may be a useful indicator for LV hypertrophy phenotype and could have a prognostic value to estimate LV-mass regression after SAVR.

BACKGROUND: Malignant intrinsic brain tumors are a hazardous disease with limited life expectancy despite intensive research in new targeted treatment options. Lately, proteasome inhibitors have been identified as potent agents causing death in glioma cell lines. It is the aim of the present study to identify proteasomal activity in the CSF of patients suffering from malignant brain tumors. METHODS: A total of 24 patients with histological confirmed brain tumors (12 malignant gliomas, 12 metastases) were included and CSF probes preoperatively analyzed for concentration and enzymatic activity of free circulating proteasome. Tumor volumina were assessed using the preoperative MRI and correlated with the CSF findings. Statistical analyses were performed using SPSS (18.0.3; SPSS Inc., Chicago, IL, USA).RESULTS: Extracellular proteasomes were found in all CSF samples showing enzymatic activity. Proteasome concentrations (28 ng/mL and 23 ng/mL, resp.) were elevated compared to a historical control group. Proteasomal enzymatic chymotrypsin-like activity was significantly raised in patients with gliomas (mean 31 fkat/ mL) compared to controls (P<0.049), whereas the enzymatic activity was not significantly elevated in metastases (P=0.109). In gliomas, neither concentration nor enzymatic activity correlated with the preoperative assessed tumor volume.CONCLUSIONS: This pilot study clearly showed that the proteasomal activity in the CSF is significantly elevated in patients with intrinsic brain tumors. Further studies need to identify the proteasomal concentration and enzymatic activity as a potential biomarker for the effectiveness of any treatment and for the early diagnosis of a possible recurrence of the disease.

Purpose Small and big conductance Ca2+-sensitive potassium (K-Ca) channels are involved in cardioprotective measures aiming at reducing myocardial reperfusion injury. For levosimendan, infarct size-reducing effects were shown. Whether activation of these channels is involved in levosimendan-induced postconditioning is unknown. We hypothesized that levosimendan exerts a concentration-dependent cardioprotective effect and that both types of Ca2+-sensitive potassium channels are involved. Methods In a prospective blinded experimental laboratory investigation, hearts of male Wistar rats were randomized and placed on a Langendorff system, perfused with Krebs-Henseleit buffer at a constant pressure of 80 mmHg. All hearts were subjected to 33 min of global ischemia and 60 min of reperfusion. At the onset of reperfusion, hearts were perfused with various concentrations of levosimendan (0.03-1 mu M) in order to determine a concentration-response relationship. To elucidate the involvement of K-Ca-channels for the observed cardioprotection, in the second set of experiments, 0.3 mu M levosimendan was administered in combination with the subtype-specific K-Ca-channel inhibitors paxilline (1 mu M, big K-Ca-channel) and NS8593 (0.1 mu M, small K-Ca-channel) respectively. Infarct size was determined by tetrazolium chloride (TTC) staining. Results Infarct size in controls was 60 +/- 7% and 59 +/- 6% respectively. Levosimendan at a concentration of 0.3 mu M reduced infarct size to 30 +/- 5% (P < 0.0001 vs. control). Higher concentrations of levosimendan did not induce a stronger effect. Paxilline but not NS8593 completely abolished levosimendan-induced cardioprotection while both substances alone had no effect on infarct size. Conclusions Cardioprotection by levosimendan-induced postconditioning shows a binary phenomenon, either ineffective or with maximal effect. The cardioprotective effect requires activation of big but not small K-Ca channels.

OBJECTIVES: Mitral valve repair is the preferred method used to address mitral valve regurgitation, whereas transcatheter mitral valve repair is recommended for high-risk patients. We evaluated the risk-predictive value of the age-adjusted Charlson comorbidity index (aa-CCI) in the setting of minimally invasive mitral valve surgery. METHODS: The perioperative course and 1-year follow-up of 537 patients who underwent isolated or combined minimally invasive mitral valve surgery were evaluated for 1-year mortality as the primary end point and other adverse events. The predictive values of the EuroSCORE II and STS score were compared to that of the aa-CCI by a comparative analysis of receiver operating characteristic curves. Restricted cubic splines were applied to find optimal aa-CCI cut-off values for the increased likelihood of experiencing the predefined adverse end points. Consequently, the perioperative course and postoperative outcome of the aa-CCI >= 8 patients and the remainder of the sample were analysed. RESULTS: The predictive value of the aa-CCI does not significantly differ from those of the EuroSCORE II or STS score. Patients with an aa-CCI >= 8 were identified as a subgroup with a significant increase of mortality and other adverse events. CONCLUSIONS: The aa-CCI displays a suitable predictive ability for patients undergoing minimally invasive mitral valve surgery. In particular, multimorbid or frail patients may benefit from the extension of the objectively assessed parameters, in addition to the STS score or EuroSCORE II. Patients with an aa-CCI >= 8 have a very high surgical risk and should receive very careful attention.

Objectives: Although off-label use of recombinant activated factor VII against refractory bleeding is incorporated in current guideline recommendations, safety concerns persist predominantly with respect to thromboembolic complications. We analyzed the safety and efficacy of recombinant activated factor VII at a very low dose in cardiosurgical patients with refractory bleeding. Methods: This prospective study includes 1180 cardiosurgical patients at risk of bleeding. Goal-directed substitution was based on real-time laboratory testing and clinical scoring of the bleeding intensity. All patients who fulfilled the criteria for enhanced risk of bleeding (n = 281) were consequently included in the present analysis. Patients in whom refractory bleeding developed despite substitution with specific hemostatic compounds (n = 167) received a single shot of very low-dose recombinant activated factor VII (<= 20 mu g/kg). Mortality and risk of thromboembolic complications, and freedom from stroke and acute myocardial infarction in particular, were analyzed (vs patients without recombinant activated factor VII) by multivariable logistic and Cox regression analyses, as well as Kaplan-Meier estimates. Results: There was no increase in rates of mortality (30-day mortality 4.2% vs 7.0% with P = .418; follow-up survival 85.6% at 13.0 [interquartile range, 8.4-15.7] months vs 80.7% at 10.2 [interquartile range, 7.2-16.1] months with P = .151), thromboembolic complications (6.6% vs 9.6% with P = .637), renal insufficiency, need for percutaneous coronary intervention, duration of ventilation, duration of hospital stay, or rehospitalization in patients receiving very low-dose recombinant activated factor VII compared with patients not receiving recombinant activated factor VII. Complete hemostasis without any need for further hemostatic treatment was achieved after very low-dose recombinant activated factor VII administration in the majority of patients (up to 88.6% vs 0% with P < .001). The key results were confirmed after adjustment by propensity score-based analyses. Conclusions: When combined with early and specific restoration of hemostatic reserves after cardiac surgery, very low-dose recombinant activated factor VII treatment of refractory bleeding is effective and not associated with any apparent increase in adverse events.

Activation of mitochondrial large-conductance Ca2+-sensitive potassium (mBKCa)-channels is a crucial step for cardioprotection by preconditioning. Whether activation of these channels is involved in levosimendan-induced preconditioning is unknown. We investigated if cardioprotection by levosimendan requires activation of mBKCa-channels in the rat heart in vitro.

Background. In the past, minimally invasive cardiac surgery (MICS)- coronary artery bypass graft surgery (CABG) alternatives have been introduced that dramatically reduce the invasiveness of standard operative procedures while still showing excellent clinical outcomes. However, in patients with high morbidity, reduced lung function impeding single-lung ventilation is one of the major concerns for MICS-CABG procedures, although those patients might reap the largest benefit from a procedure of reduced invasiveness. Methods. Here, we describe a simple surgical technique-the fan technique-that allows for continuous full-lung ventilation with unimpeded surgical view during common MICS-CABG procedures. To evaluate the procedural feasibility of this technique, we analyzed intraoperative ventilation measurements of 22 consecutive MICS-CABG patients in whom the fan technique was used. Results. This study demonstrates a significant improvement of standard respiratory measurements during procedural full-lung ventilation using the fan technique as compared with conventional single-lung ventilation (ventilation pressure 21.4 +/- 3.2 versus 26.6 +/- 3 mbar, p < 0.001; respiratory rate 13.1 +/- 1.4 versus 14.4 +/- 2.2 breaths per minute, p < 0.001; minute volume 7.4 +/- 1.1 versus 6.2 +/- 1 L/min, p < 0.0001; PaO2 during ventilation 294.9 +/- 74.6 versus 153.2 +/- 71 mm Hg, p < 0.0001). Conclusions. The presented technique may not only enable us to perform MICS-CABG procedures in patients not suitable for single-lung ventilation owing to reduced pulmonary function, but also may soon also become a standard procedure for MICS-CABG surgery, especially with regard to procedures involving complex and time-consuming multivessel revascularizations. However, further studies are strongly warranted to assess whether the fan technique may also decrease postoperative pulmonary complications and benefit clinical outcome indicators. (C) 2017 by The Society of Thoracic Surgeons

OBJECTIVESSelected patients who failed to be weaned off temporary veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support may be considered for long-term left ventricular assist devices (LVADs). Activation of the systemic inflammatory response due to the cardiopulmonary bypass (CPB) machine and its associated deleterious effects on the coagulation system have been well documented. The aim of the study was to compare the outcome of patients receiving VAD on VA-ECMO with patients who were converted to CPB at the time of VAD implantation.METHODSData of patients undergoing LVAD implantation between January 2010 and September 2015 were retrospectively reviewed. Inclusion criteria were patients with prior VA-ECMO. Perioperative characteristics and postoperative outcome of patients who received LVAD after VA-ECMO with (CPB group) or without CPB (no-CPB group) were compared.RESULTSA total of 110 permanent VADs were implanted during this time frame. Forty patients had VA-ECMO prior to VAD implantation and met the inclusion criteria. The CPB was used in 23 patients and 17 patients received VAD on VA-ECMO without using CPB. The preoperative characteristics of the patients were comparable except for lower body mass index, higher international normalized ratio (INR) and higher rate of preoperative intra-aortic balloon pump usage in the CPB group (P = 0.035, 0.008 and 0.003, respectively). The incidence of postoperative right VAD implantation and survival rate was comparable between both groups. However, the chest tube blood loss and amount of blood product usage was higher in the CPB group. The total blood loss in the first 24 h after surgery (2469 ± 2067 vs 1080 ± 941 ml, P= 0.05) and number of units of intraoperative fresh frozen plasma administered (4 ± 3 vs 1 ± 2, P= 0.02) remained higher in the CPB group even after adjustment for differences in preoperative INR value by propensity score matching.CONCLUSIONSThis study demonstrates that the CPB machine can be safely omitted when a long-term VAD is implanted on VA-ECMO support. Blood loss in the first 24 h after surgery was less and a significantly lower number of blood products were necessary in these patients compared with patients in whom the CPB machine was used. However, similar survival rates between these two groups were observed.

Central MessageWe report the safety and feasibility of implantation of the HeartMate 3 device (St Jude Medical, Inc, St Paul, Minn) using a minimally invasive approach without CPB support. Rapid extubation and limited use of blood products are the main advantages.See Editorial Commentary page 1448.Video clip is available online. We report the safety and feasibility of implantation of the HeartMate 3 device (St Jude Medical, Inc, St Paul, Minn) using a minimally invasive approach without CPB support. Rapid extubation and limited use of blood products are the main advantages. See Editorial Commentary page 1448. Video clip is available online. The HeartMate 3 left ventricular assist device (LVAD) (St Jude Medical, Inc, St Paul, Minn) is a new continuous-flow pump that has been introduced recently for clinical use after completion of clinical trials.1Netuka I. Sood P. Pya Y. Zimpfer D. Krabatsch T. Garbade J. et al.Fully magnetically levitated left ventricular assist system for treating advanced HF: a multicenter study.J Am Coll Cardiol. 2015; 66: 2579-2589Crossref PubMed Scopus (174) Google Scholar The HeartMate 3 device uses a fully magnetically levitated (Full MagLev) rotor with large blood-flow paths to minimize shear forces, which is expected to reduce detrimental effects on blood components. The inflow cannula is attached to the pump and inserted into the left ventricle, and the pump is positioned in the pericardial space. These features allow less-invasive pump implantation without the use of cardiopulmonary bypass (CPB). The feasibility of off-pump, less-invasive implantation of the HeartWare HVAD (HeartWare International, Inc, Framingham, Mass) has been demonstrated.2Bottio T. Bejko J. Gallo M. Bortolussi G. Gerosa G. Less invasive implantation of HeartWare left ventricular assist device.Multimed Man Cardiothorac Surg. July 11, 2014; ([serial online])https://doi.org/10.1093/mmcts/mmu008Crossref PubMed Scopus (12) Google Scholar, 3Khalpey Z. Smith R. Echeverria A. le Tran P. Kazui T. A novel minimally invasive off-pump biventricular assist device insertion technique.J Thorac Cardiovasc Surg. 2016; 151: e5-e7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 4Strueber M. Meyer A.L. Feussner M. Ender J. Correia J.C. Mohr F.W. A minimally invasive off-pump implantation technique for continuous-flow left ventricular assist devices: early experience.J Heart Lung Transplant. 2014; 33: 851-856Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 5Wagner C.E. Bick J.S. Kennedy J. Haglund N. Danter M. Davis M.E. et al.Minimally invasive thoracic left ventricular assist device implantation; case series demonstrating an integrated multidisciplinary strategy.J Cardiothorac Vasc Anesth. 2015; 29: 271-274Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Advantages of off-pump LVAD implantation include rapid extubation, faster rehabilitation, and lower number of blood products.2Bottio T. Bejko J. Gallo M. Bortolussi G. Gerosa G. Less invasive implantation of HeartWare left ventricular assist device.Multimed Man Cardiothorac Surg. July 11, 2014; ([serial online])https://doi.org/10.1093/mmcts/mmu008Crossref PubMed Scopus (12) Google Scholar, 3Khalpey Z. Smith R. Echeverria A. le Tran P. Kazui T. A novel minimally invasive off-pump biventricular assist device insertion technique.J Thorac Cardiovasc Surg. 2016; 151: e5-e7Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 4Strueber M. Meyer A.L. Feussner M. Ender J. Correia J.C. Mohr F.W. A minimally invasive off-pump implantation technique for continuous-flow left ventricular assist devices: early experience.J Heart Lung Transplant. 2014; 33: 851-856Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar, 5Wagner C.E. Bick J.S. Kennedy J. Haglund N. Danter M. Davis M.E. et al.Minimally invasive thoracic left ventricular assist device implantation; case series demonstrating an integrated multidisciplinary strategy.J Cardiothorac Vasc Anesth. 2015; 29: 271-274Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar We describe the technique that was used for the first 4 minimally invasive off-pump implantations of the HeartMate 3 LVAD. The left side of the patient was slightly elevated using a pillow. The CPB was primed in every patient, and a guidewire was inserted percutaneously into the femoral vein for use in emergency situations. A moderate dose of inotropic agents (milrinone and epinephrine) and nitric oxide inhalation were initiated and continued throughout the procedure. Through a J-shaped incision at the third intercostal space, an upper hemisternotomy was performed similar to the procedure used for a minimally invasive aortic valve replacement. An anterolateral minithoracotomy was performed through the fifth or sixth intercostal space on the basis of prior echocardiography assessment of the exact position of the left ventricular apex. Video 1 shows different aspects of the procedure. Several pericardial plication sutures were placed to allow exposure of the left ventricular apex. At this stage of the procedure, excessive cardiac manipulation was avoided to prevent arrhythmias. Transesophageal echocardiography (TEE) was performed to assess the proper location of the inflow cannula before the attachment of the apical sewing ring. The sewing ring was then attached to the epicardium at the apex with 8 to 10 felt pledgeted sutures. Prolene suture (Ethicon, Somerville, NJ) was placed in a running fashion along the cuff of the sewing ring to aid in securing the device. Heparin was given to achieve an activated clotting time of more than 400 seconds. A temporary pacemaker wire was attached to the left ventricle. Rapid pacing at 180 beats/min was initiated. The apex was incised within the sewing ring using a number 11 blade. Because the currently available coring knife from the HeartMate 3 device does not allow device implantation without CPB, a HeartWare coring knife was used and the coring was performed. After removal of the coring knife, the inflow from the pump was inserted into the ventricle and fixed using a fixing tool (Figure 1). Deairing was performed immediately after pump insertion by allowing blood to fill the outflow graft before it was crossclamped. Proper positioning of the inflow cannula was assessed using TEE (Figure 2). The driveline was brought out of the thoracotomy incision and tunneled. The outflow graft was then tunneled through the pericardium to the ascending aorta. An important point is not to attach the strain relief of the outflow graft before pulling the graft through the pericardium because the metal ring of the strain relief may hinder uncomplicated pulling without increasing the size of the thoracotomy incision. The aorta was partially clamped, and an end-to-side anastomosis was performed. The pump was turned on, and further deairing was performed through needles inserted in the outflow graft and ascending aorta.Figure 1The HeartMate 3 device (St Jude Medical, Inc, St Paul, Minn) in place after a left anterolateral minithoracotomy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 2TEE 4-chamber view showing the correct positioning of the HeartMate 3 pump after implantation. LA, Left atrium; RA, right atrium; LV, left ventricle; RV, right ventricle.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Four patients were supported with the HeartMate 3 device using the described technique: a 63-year-old man with dilated cardiomyopathy, a 70-year-old woman with ischemic cardiomyopathy, a 55-year-old man with dilated cardiomyopathy, and a 57-year-old man with ischemic cardiomyopathy. The average preoperative INTERMACS profile was 3.5 ± 0.6. All patients were extubated early after the procedure and have been free of serious procedure-related adverse events. These 4 cases demonstrate the safety and feasibility of implantation of the HeartMate 3 device using a minimally invasive approach without CPB support. To our knowledge, these are the first 4 patients who have been supported with the HeartMate 3 device in an off-pump technique. Because of the lack of direct visualization of the left ventricle, extreme care must be given to rule out thrombus within the left ventricle using TEE (or 3-dimensional TEE). The most critical time of this procedure is when the apical coring is performed. Some surgeons have described the use of adenosine or coring on the beating heart (used for patients 3 and 4) for off-pump LVAD implantation, but these are anecdotal experiences and the optimal technique is yet to be determined.2Bottio T. Bejko J. Gallo M. Bortolussi G. Gerosa G. Less invasive implantation of HeartWare left ventricular assist device.Multimed Man Cardiothorac Surg. July 11, 2014; ([serial online])https://doi.org/10.1093/mmcts/mmu008Crossref PubMed Scopus (12) Google Scholar, 4Strueber M. Meyer A.L. Feussner M. Ender J. Correia J.C. Mohr F.W. A minimally invasive off-pump implantation technique for continuous-flow left ventricular assist devices: early experience.J Heart Lung Transplant. 2014; 33: 851-856Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar Minimally invasive off-pump implantation of the HeartMate 3 device seems to be feasible and safe. However, the currently available surgical tools allow minimally invasive implantation but only with CPB. Therefore, at this stage, we recommend using the HeartWare coring knife at the time of coring, which facilitates the off-pump implantation. Further studies are needed to confirm the advantages of off-pump LVAD implantation compared with conventional implantation procedures using CPB.

OBJECTIVES According to demographic changes in the industrialized world, the average age of patients referred to cardiac surgery is increasing. These patients typically display numerous comorbidities, associated with increased perioperative risk. Therefore, the indication for a catheter-based therapy is progressively extended, including interventions on the mitral valve (MV). In this context, we evaluated a contemporary series of octogenarians undergoing minimally invasive MV surgery at our institution using right lateral minithoracotomy to elucidate the preoperative risk profile and the postoperative course in this particular cohort. METHODS Between October 2009 and October 2014, 34 patients aged 80 years and older (82.5 ± 2.0) undergoing minimally invasive MV surgery were identified with a subgroup of 15 patients (44.1%) receiving concomitant surgery on the tricuspid valve (TV). We analysed the preoperative profile, perioperative course and functional outcome. RESULTS Preoperative comorbidities included insulin-dependent diabetes mellitus (17.6%), COPD (17.6%), active endocarditis (2.9%) and previous neurological events (2.9%). The mean left ventricular ejection fraction was 59.7 ± 6.9%. Mean European System for Cardiac Outcome Risk Evaluation II was 5.2 ± 5.3%. The repair rate of all treated MVs and TVs in isolated and combined procedures was 81.6% (73.5% for MV and 100.0% for TV surgery). Postoperatively, 4 patients (11.8%) required new-onset intermittent haemodialysis. Prolonged ventilation (>12 h) was necessary in 9 patients (26.5%). The 30-day mortality rate was 5.9%. CONCLUSIONS Minimally invasive right lateral MV surgery in octogenarians results in favourable outcomes. Therefore, MV surgery represents a valid option in this cohort, providing established and durable concepts of valve reconstruction.

BackgroundCCL18 is a CC chemokine produced mainly by antigen-presenting cells, and is chemotactic predominantly for T-lymphocytes. CCL18 can stimulate pulmonary fibroblasts and increase the collagen production in vitro.ObjectivesThis study aimed to compare the CCL18 levels in a variety of human biological fluids between various interstitial lung diseases (ILDs), and to reveal potential correlations with BAL cell differentials.MethodsSerum and bronchoalveolar lavage fluid (BALF) samples were collected from 199 patients with idiopathic pulmonary fibrosis (IPF), idiopathic non-specific interstitial pneumonia (iNSIP), respiratory bronchiolitis interstitial lung disease/desquamative interstitial pneumonia (RB-ILD/DIP), cryptogenic organizing pneumonia (COP), hypersensitivity pneumonitis (HP) or sarcoidosis. Alveolar macrophage (AM) culture was performed in 44 patients with IPF, iNSIP, COP, HP, sarcoidosis or non-ILDs. The CCL18 levels in serum, BALF and AM culture supernatant were measured with ELISA.ResultsBoth serum and BALF CCL18 levels in all ILDs were higher than in controls (all p < 0.005). In HP, CCL18 serum levels were the highest of all ILDs, and its BALF levels were significantly higher than in other ILDs except iNSIP. The BALF CCL18 levels markedly correlated with BAL cell differentials, especially with the percentage of BAL lymphocytes. In AM culture supernatant, the spontaneous CCL18 production was higher in HP and COP than in IPF and controls.ConclusionCCL18 levels in serum, BALF and AM culture supernatant are markedly increased in various inflammatory and fibrotic ILDs. However, the CCL18 level being highest in HP among the investigated ILDs suggests that CCL18 may be more profoundly involved in inflammatory immune responses.

The repair mechanism resulting in alveolar protein degradation is largely unknown. In the alveolar space the presence of extracellular, biologically active proteasomes are recently reported [1,2]. The proteasome is involved in protein degradation and is able to degrade proteins at a high rate, possibly to minimize oncotic pressure [1]. We tested proteasome release by alveolar epithelial cells type II (AEC-II). AEC-II were isolated from 24 macroscopically tumour-free lung tissues as described previously [3]. Cells were stimulated with dibutyryl cAMP; for second part of the study after levelling with 1 µM indomethacin and 10 nM PGE2. Unstimulated AEC-II and primary isolated PBMC served as control. Extracellular proteasome concentration was measured by an established ELISA targeting the proteasome in supernatant. For statistical evaluation the Wilcoxon signed rank test was applied. Our study demonstrates for the first time that human non-tumourous AEC-II do release proteasomes. Stimulated with db-cAMP, the extracellular proteasome concentration (median unstim. 700 ng/mL) results in a wide insignificant range (median stim. 600 ng/ml). Indeed after levelling with indomethacin and PGE2 (median unstim. 400 ng/ml) the stimulation with db-cAMP. increases proteasome release highly significantly (stim. 460 ng/ml). Unchanged proteasome concentration in the alveolar fluid showed no artificial elution of the proteasomes by the pre-smoking lavage. In conclusion, AEC-II release proteasomes cAMP-dependent into the alveolar space. [1] Sixt, S.U. et al. Am J Physiol Lung Cell Mol Physiol 2007; 292:L1280-8 [2] Sixt, S.U. et al. Am J Respir Crit Care Med 2009; 179:1098-106. [3] Hoehne, K. et al. PLoS One 2012; 7:e38369.

Background: Angiogenesis-angiostasis balance and leukocyte recruitment are influenced by different concentrations of distinct chemokines. Objective: To investigate the relative contribution of angiogenic and angiostatic CXC chemokines to the pathogenesis of idiopathic pulmonary fibrosis (IPF) and granulomatous lung diseases, we examined the in vitro production of an angiogenic chemokine (IL-8), and 2 angiostatic chemokines (IP-10 and MIG) by alveolar macrophages. Methods: Alveolar macrophages from 16 patients with granulomatous lung diseases [8 with sarcoidosis, 8 with extrinsic allergic alveolitis (EAA)], 16 patients with IPF, and 8 control subjects were cultured for 24 h. IL-8, IL-18, IP-10 and MIG in the culture supernatants were measured by a fluorescent bead-based multiplex technique. Results: In IPF patients, IL-8 was increased and correlated with bronchoalveolar lavage (BAL) neutrophils, whereas the levels of IP-10 and MIG were normal. In sarcoidosis and EAA patients, IL-8, IP-10, and MIG were all increased and IP-10 and MIG correlated with IL-18, a Th1 cytokine, and the percentage and number of BAL lymphocytes. Conclusions: The difference in the expression of CXC chemokines and a Th1 cytokine may contribute to the different immunopathogenesis, clinical course and responsiveness to treatment of these diseases.