Background/Objectives: Early tracheostomy seems favorable in prolonged ventilated patients after surgery. Hence, predicting tracheostomy after cardiac surgery is essential. Recently proposed prediction models aim to support this decision-making process, but their diagnostic validity across other patient populations remains uncertain. Methods: A retrospective single-center study was performed at a university hospital. The patient sample included consecutive patients between 2010 and 2020 who underwent cardiac surgery. Patients who underwent tracheostomy after cardiac surgery were assigned to the intervention group. Control group patients, who had not undergone tracheostomy, were randomly assigned to the group. An existing model was evaluated by receiver operating characteristics curve analysis. Four sets of risk features were chosen depending on results from regression analysis, lasso regularization, random forest or clinical domain knowledge. Newly developed models were created using machine learning methods: random forest, naïve Bayes, nearest neighbor and deep learning. Multiple models were trained with either feature set and then assessed using confusion matrices on an independent test set. Results: A total of 4744 patients were included in this study. One-hundred and eighteen patients were included in the tracheostomy group. Diagnostic accuracy of the existing model showed insufficient discrimination (area under the curve (AUC) = 0.57). Likewise, newly developed models also showed overall poor diagnostic discrimination across all feature sets and algorithms. Conclusions: This study shows the diagnostic limitations of retrospective clinical data for the diagnostic prediction of tracheostomy, thereby informing the design of future prospective diagnostic studies. Training new models should not rely on retrospective data alone. Instead, prospective data collection and integration of physiological or imaging-based diagnostics could likely contribute to the development of a good classifier.

Hyperglycemia and diabetic ketoacidosis are serious and life-threatening emergencies in diabetes patients. Early recognition of the symptoms of these disorders and their management are essential. Therapy is adequate rehydration, insulin treatment, electrolyte replacement, and handling of the underlying causative disease. Herein, we present an 83-year-old male with an extremely altered blood gas analysis after a surgical procedure of his left hand due to a phlegmon and describe the successful treatment through intensive care.

Journal Article Reply to Condello Get access Felix Wiesmueller, Felix Wiesmueller Department of Surgery, University Hospital of Greifswald, Greifswald, 17475 Germany Corresponding author. Department of Surgery, University Hospital of Greifswald, 17475 Greifswald, Germany. Tel: 00493834860; e-mail: felix.wiesmueller@med.uni-greifswald.de (F. Wiesmueller). https://orcid.org/0000-0002-6101-804X Search for other works by this author on: Oxford Academic PubMed Google Scholar Thomas Strecker Thomas Strecker Department of Cardiac Surgery, University Hospital of Erlangen, Erlangen, 91054 Germany Search for other works by this author on: Oxford Academic PubMed Google Scholar European Journal of Cardio-Thoracic Surgery, Volume 63, Issue 6, June 2023, ezad206, https://doi.org/10.1093/ejcts/ezad206 Published: 09 June 2023 Article history Received: 01 May 2023 Published: 09 June 2023 Corrected and typeset: 22 June 2023

Streptococcal toxic shock syndrome is a severe, invasive and life-threatening infection associated with a high risk of rapid multiorgan failure. It is associated with high morbidity and mortality. Streptococcal toxic shock syndrome is very commonly caused by group A- Streptococcus pyogenes , ß-haemolytic streptococcus, a typical human-specific gram-positive bacterial pathogen. We present here the case report of a 54-year-old man with a rapidly progressive streptococcal toxic shock syndrome due to necrotising fasciitis of the left lower limb and describe the successful treatment through close interdisciplinary care.

OBJECTIVES: Risk factors associated with intestinal ischaemia after heart surgery have been previously explored; however, a paucity of data exists with regard to extent of intestinal ischaemia in patients requiring surgical intervention. The purpose of this study is to assess predictors of abdominal exploration and extent of ischaemia following cardiac surgery. METHODS: A retrospective single-centre study was performed at a university hospital. The patient sample included consecutive patients between 2009 and 2020 who first received cardiac and then abdominal exploration during the same hospital stay. Control group patients were identified by 1:1 propensity matching. Logistic regression was performed to identify risk factors for laparotomy. Patients of the laparotomy group were further analysed for intraoperative findings from required abdominal operations. RESULTS: A total of 6832 patients were identified, of whom 70 (1%) underwent abdominal exploration. The median time to exploratory laparotomy was 6 days with no difference between intraoperatively confirmed ischaemia versus those who underwent negative exploration. Thirty-day mortality was 51%. Prior diagnosis of COPD or administration of 2 or more vaso-inotropes during the postoperative phase was independent risk factors for exploratory laparotomy. Vaso-inotrope use was a strong independent predictor of extent of intestinal ischaemia as well as for 30-day mortality. Degree of intestinal ischaemia was also an independent predictor of 30-day mortality. CONCLUSIONS: Intestinal ischaemia is a feared complication after cardiac surgery with high mortality, often necessitating multiple abdominal procedures. Administration of 2 or more vaso-inotropes in the postoperative phase of cardiac procedure is a strong predictor for the degree of ischaemia and 30-day mortality.

Aortic dissection is a life-threatening cardiovascular disease. Hereditary disorders are responsible for a small percentage of cases. Nonetheless, it is important to identify genetic causes, as they are often autosomal dominantly inherited and are of life-saving importance if we can identify persons at risk. Mutations of the ACTA2 gene are the most common cause of non-syndromic familial aortic disease. Exploration of the genetic background in suspected familial cases and determination of the exact etiology are mandatory for management and establishing appropriate follow-up strategies due to the risk of fatal recurrences. Herein, we present a 21-year-old male with a familial acute aortic dissection associated with novel ACTA2 germline variant and discuss the management and surveillance considerations.

A 70-year-old Caucasian man with a history of previous mitral valve replacement, 46 years before, was referred to our hospital with symptoms of relapsing heart failure. Actually, he noted progressive dyspnea, oedema, cough, and slightly general chest and abdominal pain. In January 1974, at age 24 years, he had undergone mitral valve replacement with the use of a Starr-Edwards disk valve (CED 28M) due to severe mitral valve stenosis and thrombus resection from the left atrium. The patient had been in his usual state of good health according to his age until a couple of months before admission to the hospital. At admission, the results of the physical examination were almost unremarkable. Blood analysis, coagulation, and electrolyte parameters were within the normal range with the exception of mild chronic renal insufficiency, creatinine was 1.9 mg/dL. The patient presented with a blood pressure of 112/66 mm Hg and atrial fibrillation with 90 beats per minute. Transthoracic echocardiography (TTE) revealed a moderate tricuspid valve insufficiency with a vena contracta of 8 mm, a dilated right atrium and ventricle with a mid-impaired right ventricular function (Figure 1A, Video S1). The left atrium was moderate dilated, the left ventricle was normal with almost no impairment of the left ventricular ejection fraction. The previously implanted mechanical mitral valve prosthesis shows a normal movement, normal pressure gradient, ∆pmax/mean 8/3 mm Hg, and no leakage (Figure 1B, Video S2). Subsequently, selective invasive coronary angiography revealed no significant stenosis of the left main, the left anterior descending, the circumflex, or the right coronary artery (Figure 1C, Video S3). Furthermore, computed tomography (CT) was performed. The CT demonstrated prominent calcification surrounding the dilated left atrium consistent with constrictive pericarditis (Figure 1D). The Starr Edwards disk valve is a second-generation mechanical valve prosthesis introduced in early 70 seconds after the first mechanical ball valve prostheses at the beginning of the 60 seconds. Since that time many research and investigations have been made to find the perfect mechanical and biological valve prosthesis to avoid or at least reduce the known complications like thromboembolic events or infections.1, 2 In the literature, we could find a few case reports of such original aortic or mitral valves prostheses with a durability up to 50 years.3, 4 Our Heart Centre also has a very long tradition in cardiac surgery, so that we see patients again and again far behind their first heart operations.5, 6 In view of the clinical findings and considering the increased surgical risk of reoperation due to the intramural constrictive pericarditis, we have decided against a conventional operative therapy with replacement or reconstruction of the tricuspid valve. Of course, we have also thought about alternative interventional procedures. The effectiveness and feasibility of the new transcatheter tricuspid valve implantation (TTVI) with valve-bearing vascular prosthesis could be demonstrated in previous studies.7 Nevertheless, we initially opted for conservative therapy. We have expanded and optimized drug therapy by increasing diuretics and heart failure medications. The patient made an almost uneventful recovery, with significant improvement in his pulmonary and renal functions. Before leaving the hospital, the TTE showed a slight impairment of left ventricular function with an ejection fraction of 50%, a dilated right ventricle with a moderate tricuspid insufficiency and a well-functioning mitral valve prosthesis, no intracardiac masses, and no pericardial effusions. We are aware of the limitations of oral home medication. Should the regular outpatient checks with laboratory parameter and echocardiography show further deterioration of the general condition or severe tricuspid insufficiency, then the TTVI would be a good alternative in experienced hands. Procedural and clinical outcomes of transcatheter tricuspid valve repair therapies are expected to improve in the coming years with technological advancement and the introduction of newer devices.8 Although there is no doubt regarding the order of the different therapies (medical drugs, interventions, and operations) in established general practice, in the presented special case, we considered a conventional reoperation with the risks mentioned above to be the last therapeutic option suitable for this patient. The reported case illustrates the very long durability of a Starr-Edwards disk mitral valve prosthesis over 46 years. Our conservative treatment was justified to prevent perioperative and later postoperative complications. We acknowledge support by the “Deutsche Forschungsgemeinschaft” and the Friedrich-Alexander-University Erlangen-Nurnberg (FAU) within the funding program Open Access Publishing. The authors declare that there are no conflict of interests. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Primary cardiac tumors are very rare entities, atrial myxomas being the most common type. However, with increased imaging examinations and the use of high‐resolution technologies, incidentally discovered tumors and smaller lesions become more and more frequent. Here we report the diagnostic evaluation and successful surgical resection of such a cardiac myxoma in 65‐year‐old Caucasian males that developed and became symptomatic within 1 year. Notably, computed tomography and echocardiography performed 1 year before could not detect the tumor, even after critical retrospective evaluation. Primary cardiac tumors are rare entities, atrial myxomas being the most common type. However, with increased imaging examinations and the use of high‐resolution technologies, incidentally discovered tumors and smaller lesions become more frequent. Here we describe the diagnostic evaluation and successful surgical resection of a cardiac myxoma that developed and became symptomatic within 1 year after unremarkable prior imaging. Notably, computed tomography (Figure 1A) and echocardiography performed 1 year before could not detect the tumor, even after critical retrospective evaluation. A 65‐year‐old Caucasian male with symptoms of heart failure (NYHA Class III) for 2 months and recurring atrial fibrillation was referred to our hospital for further diagnostic evaluation. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) revealed a suspicious mass within the left atrium (LA) attached to the anterior wall with moderately impaired left ventricular ejection fraction of 35%. Subsequently, cardiac computed tomography (CT) verified the described tumor mass (diameter 12mm × 17mm× 17mm) (Figure 1B). The patient was taken to the operating theater, where a median sternotomy was performed and cardiopulmonary bypass was installed through aorto‐right atrium cannulation. After opening of the LA, the sessile mass was successfully excised. The resulting defect in the septum was then directly closed. The patient was easily weaned from cardiopulmonary bypass. She made an uneventful recovery, extubated on the second postoperative day, and transferred to intermediate care on day 4. Before leaving the hospital, the TTE showed a moderate impairment of ventricular function, well‐ functioning heart valves, no intracardiac masses, and no pericardial effusions. Histological examination of the excised tumor confirmed the diagnosis of atrial myxoma (Figure 1C,D). Clinical symptoms of cardiac tumors could be absent or nonspecific, resulting in delayed diagnosis and treatment. The radiological evaluation of these neoplasms has been greatly facilitated by the development of noninvasive cardiac imaging, that is, TTE and TEE, CT and magnetic resonance tomography (MRT). Nevertheless, there are only very few case reports in the literature describing the growth rate of these tumors, mostly in infants or in the elderly. The first report on this topic appeared in 1983. In most reports, there was no clearly defined starting point, so that the exact growth speed of the tumor cannot be reliably assessed. The current report demonstrates the necessity to include cardiac tumors in the differential diagnosis of newly appearing lesions even after unremarkable recent cardiac imaging and to differentiate them from reactive or thrombotic lesions.

The authors declare that there is no conflict of interests. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

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Small cell carcinoma of the ovary, hypercalcemic type (SCCOHT), is a rare SMARCA4-driven aggressive malignancy of young age characteristically associated with paraneoplastic hypercalcemia. Comparable neoplasms/presentations have not been reported in males. A 39-year-old male heart transplant recipient (HTX 40 months previously) presented with multiple liver nodules and hypercalcemic crisis. The serum parathyroid hormone-related protein (PTHrp) was significantly elevated (241 pg/ml; reference value < 57). Liver biopsy showed poorly differentiated partially rhabdoid neoplasm expressing pancytokeratin, CK20, and focally GATA3, SATB2, p63, and SALL4. The tumor cells showed dual loss of SMARCA4 and SMARCA2. He died of irreversible multiorgan failure one week after admission. To our knowledge, this is the first report highlighting the rare occurrence of paraneoplastic hypercalcemia associated with SMARCA4-deficient malignancies in males. Although the immunophenotype suggests urothelial or upper gastrointestinal tract origin, the exact primary tumor site could not be ascertained due to rapid death of the patient. SMARCA4 immunohistochemistry should be included in the workup of neoplasms associated with hypercalcemia irrespective of gender and site.

Background . Lipomatous hypertrophy of the atrial septum (LHAS) is a rare entity characterized by mass-forming deposition of fatty tissue within the atrial septum. To date, <300 cases have been reported; many of them were autopsy findings. The clinical presentation of LHAS varies from incidental asymptomatic mass (most frequent form) to severe life-threatening cardiovascular complications necessitating emergency cardiac surgery. Case Presentation . Here, we present the successful surgical resection of such a massive LHAS which was found incidentally on preoperative investigation of a 71-year-old patient with progressive coronary heart disease. Histology confirmed the diagnosis of lipomatous hypertrophy of the atrial septum. Conclusions . The described case report illustrates an unusual example of LHAS in a patient undergoing a planned coronary artery bypass surgery. In this case, surgical intervention was justified to avoid later outflow obstructions.

Acute aortic dissection is a life-threatening condition mainly caused by hypertension, atherosclerotic disease and other degenerative diseases of the connective tissue of the aortic wall. Mesothelial/monocytic incidental cardiac excrescences (cardiac MICE) is a rare benign reactive tumor-like lesion composed of admixture of histiocytes, mesothelial cells, and inflammatory cells set within a fibrinous meshwork without a vascular network or supporting stroma. Cardiac MICE occurring in association with aortic dissection is exceptionally rare (only one such case reported to date). We herein report on the surgical repair of two Stanford type A aortic dissections caused by idiopathic giant cell aortitis in a 66-year-old-woman and by atherosclerotic disease in a 58-year-old-man, respectively. In both cases, the dissections could be visualized via computed tomography. Histopathology showed cardiac incidental MICE within the external aortic wall near the pericardial surface which was confirmed by immunohistochemistry.

Background and aim: Ventricular assist devices (VAD) have become an established therapy for patients with end-stage heart failure. The two main reasons for this development are the shortage of appropriate donor organs and the increasing number of patients waiting for heart transplantation (HTX). Furthermore, the enormous advances in the technical equipment and the rising clinical experience have improved the implantation technique, the durability and the long-term patient outcomes. Methods: We reviewed all cases of left ventricular assist device (LVAD) implantation at our Erlangen Heart Center during January 2000-July 2013. The main aim of this study was to analyze the underlying pathology from the cardiac apex removed during the implantation. From all patients, we created a follow-up, analyzed the pathological features with the clinical diagnoses and described the overall outcome. Results: VAD implantation was performed in 266 cases at our center in the last 13 years (2.2% of the total of 12254 cardiac surgical operations in that period). From these patients, 223 underwent LVAD or biventricular (BVAD) implantation; the remaining received a right (RVAD) implantation. The most frequent underlying clinical diagnoses were dilated (n = 84, 37.7%, DCM) or ischemic (n = 61, 27.4%, ICM) cardiomyopathy. The pathological findings in the apex biopsy were generally non-specific and showed variable interstitial myocardial fibrosis with evidence of fibre loss, fatty degeneration and variable irregular atrophy of muscle fibres, consistent with dilated and ischemic cardiomyopathies as the most frequent causes of heart failure in these patients. Only a few cases showed other specific features such as myocarditis and AL-amyloidosis. Conclusions: Pathological findings in cardiac apex removed during LVAD implantation are rather non-specific and they generally reflect the late stage or consequences of chronic myocardial damage in cases of dilated or ischemic cardiomyopathies. Variable patchy chronic inflammatory changes may be observed in cardiomyopathies as a non-specific reaction caused by myocardial fiber damage and should not lead to misinterpretation as evidence of myocarditis or revision of original diagnosis.

Primary cardiac tumors are very rare, papillary fibroelastoma (PFE) being the second most common benign tumor of the heart in previous series. However, as a consequence of increased imaging examinations, incidental PFE may represent the most common cardiac tumor. Their clinical presentation varies from incidental asymptomatic masses to severe life-threatening cardiovascular complications necessitating emergency surgery. Here we report the diagnostic evaluation and successful surgical resection of such a cardiac tumor in a 67-year-old woman. Histology confirmed diagnosis of a papillary fibroelastoma. This report demonstrates it’s necessary to include cardiac tumors in the differential diagnosis of subtle and non-specific cardiothoracic symptoms.

Introduction. For patients with terminal heart failure, heart transplantation (HTX) has become an established therapy. Before transplantation there are many repeated measurements with a pulmonary artery catheter (PAC) via the superior vena cava (SVC) necessary. After transplantation, endomyocardial biopsy (EMB) is recommended for routine surveillance of heart transplant rejection again through the SVC.Case Presentation. In this report, we present a HTX patient who developed a SVC syndrome as a possible complication of all these procedures via the SVC. This 35-year-old Caucasian male could be successfully treated by balloon dilatation/angioplasty.Conclusion. The SVC syndrome can lead to pressure increase in the venous system such as edema in the head and the upper part of the body and further serious complications like cerebral bleeding and ischemia, or respiratory problems. Balloon angioplasty and stent implantation are valid methods to treat stenoses of the SVC successfully.

Primary cardiac tumors are very rare, atrial myxoma being the most common benign tumor of the heart. They may present with a great variety of incidental asymptomatic masses to severe life-threatening cardiovascular complications necessitating emergency surgery. Here we report the diagnostic evaluation and successful surgical resection of such a giant cardiac tumor which was found on a routine medical check-up in a 62-year-old patient. Histology confirmed diagnosis of unusually huge myxoma. This article demonstrates it's necessary to include cardiac tumors in the differential diagnosis of subtle and non-specific cardiothoracic symptoms.

BACKGROUND AND AIM:Heart transplantation (HTX) has become an established therapy for patients with end-stage heart failure. However, cancer incidence has been shown to be increased in the context of transplant-associated immunosuppression. The objective of this study is to analyze the incidence, histological spectrum, treatment and survival of various cancer types in HTX patients.METHODS:We evaluated retrospectively all patients who underwent orthotopic HTX between 2000 and 2011 at our hospital including those patients who underwent HTX in other centers, but did their routine follow-up examinations at our department because of changing residence.RESULTS:142 patients had HTX performed at our center in the last 11 years and another 9 patients visited our department for monitoring after HTX performed at an external center (total: 151). Ten patients (6.6%) developed a metachronous malignancy (3 non-melanoma skin cancer, 2 lung cancer and 1 each parotid gland cancer, prostate cancer, renal cancer, urinary bladder cancer and ductal pancreatic cancer). The latency between HTX and the diagnosis of the secondary neoplasm ranged from 33 to 152 months (median 76 months; mean 88 months). In all cases, surgery with or without chemoradiation was the treatment for the metachronous cancer. While most cases followed a favorable course after appropriate surgical and/or oncological treatment, four tumors (1 salivary duct carcinoma, 1 urinary bladder carcinoma, 1 ductal pancreatic cancer and 1 skin cancer) revealed a remarkable aggressiveness with wide-spread metastatic disease at the time of diagnosis or shortly thereafter.CONCLUSIONS:Incidence of various cancer types among HTX patients in this survey was consistent with previous studies, with lung and skin cancer as the commonest malignancies encountered. Regular cancer screening may be of benefit in reducing morbidity and mortality in these patients.

BACKGROUND & AIM Aortic aneurysms represent one of the major causes of cardiovascular surgery. Their etiology varies greatly based on patient's age and other clinicopathologic determinants. In addition to common atherosclerotic vascular diseases, an inflammatory etiology, in particular IgG4-related disease (IgG4-RD) has increasingly emerged as a cause of dissecting inflammatory aortic aneurysms (IAA). METHODS To assess the frequency and types of IAA, we reviewed all cases of aortic aneurysms resected at our Erlangen Heart Center during 2000-2013. RESULTS 376 patients underwent resection of aortic aneurysms in the study period. These are further categorized as ascending aortic aneurysms (45%), aortic arch aneurysm (2%), descending aortic aneurysm (3%), type A dissection (46%) and type B dissection (4%). Fifteen cases (4%) showed variable lymphoplasmacytic inflammation thus qualifying as IAA. Affected were 9 females and 6 males (female to male ratio = 1.5:1; age range: 52-80 yrs; mean: 70 yrs; median: 72 yrs). None was known to have IgG4-RD and serum IgG4 and/or IgG levels (known in 6 cases) were normal. Variable sclerosing lymphoplasmacytic inflammation was seen either confined to the adventitia (periaortitis; mainly in males) or extending through all layers (mainly in females). A wide range of IgG4 plasma cells (range: 3-182/HPF; mean: 51/HPF) and IgG4: IgG ratios (range: 0.02 to 0.91; mean: 0.37) were detected. All but one of the cases with at least focally transmural inflammation showed a higher IgG4: IgG ratios in excess of 0.3 (range, 0.32-0.91; median, 0.62). Lymphoid follicle and variable fibrosis were common but obliterative phlebitis was not seen. CONCLUSION IgG4-rich sclerosing lymphoplasmacytic thoracic aortitis is a constant histological feature of thoracic IAA. Normal serum IgG4 in most patients, predilection for women and absence of other features of IgG4-RD all suggest a tissue-specific localized autoimmunological process and argue against a systemic disorder. The relationship (if any) of IgG4-rich lymphoplasmacytic thoracic aortitis in those patients with IAA lacking other organ manifestations or an elevated serum IgG4 level to systemic IgG4-RD remains unclear and merit further studies.