Publications by authors named "Daniel Wendt"

142 Publications

Coronary Artery Bypass Graft Surgery in Patients With Acute Coronary Syndromes After Primary Percutaneous Coronary Intervention: A Current Report From the North-Rhine Westphalia Surgical Myocardial Infarction Registry.

J Am Heart Assoc 2021 Sep 13:e021182. Epub 2021 Sep 13.

Department of Cardiothoracic Surgery University-Hospital of Cologne Cologne Germany.

Background Coronary artery bypass grafting has remained an important treatment option for acute coronary syndromes, particularly in patients (1) with ongoing ischemia and large areas of jeopardized myocardium, if percutaneous coronary intervention (PCI) cannot be performed; (2) following successful PCI of the culprit lesion with further indication for coronary artery bypass grafting; and (3) where PCI is incomplete, not sufficient, or failed. Methods and Results We aimed to analyze coronary artery bypass grafting outcome following prior PCI in acute coronary syndromes from the North-Rhine-Westphalia surgical myocardial infarction registry comprising 2616 patients. Primary end points were in-hospital all-cause mortality and major adverse cardio-cerebral event. Patients were 68±11 years of age, had 3-vessel and left main-stem disease in 80.4% and 45.3%, presenting a logistic EuroSCORE of 15.1% in unstable angina, 20.3% in non-ST-segment-elevation myocardial infarction, and 23.5% in ST-segment-elevation myocardial infarction. A history of PCI was present in 36.2% and PCI was performed within 24 hours before surgery in 5.2% in unstable angina, 5.9% in non-ST-segment-elevation myocardial infarction, and 16.1% in ST-segment-elevation myocardial infarction. PCI failed in 5.3% in unstable angina, 6.8% in non-ST-segment-elevation myocardial infarction and 17.2% in ST-segment-elevation myocardial infarction, and 28.8% of patients presented with cardiogenic shock. In-hospital mortality without PCI was 7.4%, but increased to 8.7% with prior PCI >24 hours, 14.5% with prior PCI <24 hours, and 14.1% with failed PCI (<0.003). The in-hospital major adverse cardio-cerebral event rate was 16.4% without PCI, but 17.4% with prior PCI >24 hours, 25.6% with prior PCI <24 hours, and 41.3% with failed PCI (=0.014). Multivariable logistic regression analysis showed prior PCI (=0.039), as well as failed PCI (=0.001) to be predictors for in-hospital all-cause mortality and major adverse cardio-cerebral event. Conclusions In the current PCI era, immediately prior or failed PCI before coronary artery bypass grafting in acute coronary syndromes is associated with high perioperative risk, cardiogenic shock, and increased morbidity and mortality.
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http://dx.doi.org/10.1161/JAHA.121.021182DOI Listing
September 2021

Mitral surgical redo versus transapical transcatheter mitral valve implantation.

PLoS One 2021 25;16(8):e0256569. Epub 2021 Aug 25.

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.

Background: Transcatheter methods have been rapidly evolving to provide an alternative less invasive therapeutic option, mainly because redo patients often present with multiple comorbidities and high operative risk. We sought to evaluate and compare our experience with transapical transcatheter mitral valve replacement (TA-TMVR) to conventional redo mitral valve replacement in patients presenting with degenerated biological mitral valve prostheses or failed valve annuloplasty.

Methods And Material: Between March 2012 and November 2020, 74 consecutive high-risk patients underwent surgical redo mitral valve replacement (n = 33) or TA-TMVR (n = 41) at our institution. All patients presented with a history of a surgical mitral valve procedure. All transcatheter procedures were performed using the SAPIEN XT/3™ prostheses. Data collection was prospectively according to MVARC criteria.

Results: The mean logistic EuroSCORE-II of the whole cohort was 19.9±16.7%, and the median STS-score was 11.1±12.5%. The mean age in the SMVR group was 63.7±12.8 years and in the TMVR group 73.6±9.7 years. Patients undergoing TA-TMVR presented with significantly higher risk scores. Echocardiography at follow up showed no obstruction of the left ventricular outflow tract, no paravalvular leakage and excellent transvalvular gradients in both groups (3.9±1.2 mmHg and 4.2±0.8 mmHg in the surgical and transcatheter arm respectively). There was no difference in postoperative major adverse events between the groups with no strokes in the whole cohort. Both methods showed similar survival rates at one year and a 30-day mortality of 15.2% and 9.8% in SAVR and TMVR group, respectively. Despite using contrast dye in the transcatheter group, the rate of postoperative acute kidney failure was similar between the groups.

Conclusion: Despite several contraindications for surgery, we showed the non-inferiority of TA-TMVR compared to conventional surgical redo procedures in high-risk patients. With its excellent hemodynamic and similar survival rate, TA-TMVR offers a feasible alternative to the conventional surgical redo procedure in selected patients.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0256569PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8386843PMC
August 2021

The frozen elephant trunk technique: impact of proximalization and the four-sites perfusion technique.

Eur J Cardiothorac Surg 2021 Aug 11. Epub 2021 Aug 11.

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany.

Objectives: To improve organ protection with the frozen elephant trunk (FET) procedure, a so-called four-sites perfusion in combination with proximalization for the distal aortic anastomosis was performed. The impact of these techniques on patient outcome is reported.

Methods: Between February 2005 and April 2020, a total of 357 patients underwent the FET procedure for acute (54%) or chronic (22%) aortic dissection or aneurysmal disease (24%). The level of the distal FET anastomosis was defined according to aortic arch zones 0-3. Patients were divided into 3 groups according to the intraoperative perfusion strategy: (i) selective antegrade cerebral perfusion (SACP) alone (N = 96, 2 sites); (ii) SACP plus left subclavian artery or distal aorta (N = 84, 3 sites) and (iii) SACP plus left subclavian artery plus distal aorta (N = 177, 4 sites). Early outcome was addressed by a composite end point: occurrence of either a disabling stroke, a disabling spinal cord injury, extracorporeal circulatory support, kidney dialysis or death within 90 days.

Results: Preoperative characteristics were similar among the groups. Surgery in group C was characterized by FET proximalization in arch zone ≤2, moderate hypothermia at 28°C and shorter periods of extracorporeal circulation, SACP, hypothermic circulatory arrest and cardioplegic arrest (P < 0.001, respectively). Occurrence of the composite end point was reduced in group C (P = 0.008). The combination of FET proximalization and four-sites perfusion was a protective factor for the composite outcome in multivariable analysis (P = 0.009). The 5-year survival was improved in patients who underwent FET proximalization in zone ≤2 (hazard ratio 0.7, 95% confidence interval 0.4-1.0; P = 0.036).

Conclusions: FET proximalization in combination with four-sites perfusion has the potential to improve patient outcomes in terms of survival and major events.

Subject Collection: 120; 161.
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http://dx.doi.org/10.1093/ejcts/ezab295DOI Listing
August 2021

Geometric changes in aortic root replacement using Freestyle prosthesis.

J Cardiothorac Surg 2021 Jul 28;16(1):204. Epub 2021 Jul 28.

Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center Essen, Essen, Germany.

Background: The Medtronic Freestyle prosthesis has proven to be a promising recourse for aortic root replacement in various indications. The present study aims to evaluate clinical outcomes and geometric changes of the aorta after Freestyle implantation.

Methods: Between October 2005 and November 2020, the computed tomography angiography (CTA) data of 32 patients were analyzed in a cohort of 68 patients that underwent aortic root replacement using Freestyle prosthesis. The minimum and maximum diameters and areas of the aortic annulus, aortic root, ascending aorta, and the proximal aortic arch were measured at a plane perpendicular to the long axis of the aorta using 3D multiplanar reconstruction in both the preoperative (n = 32) and postoperative (n = 10) CTAs. Moreover, volumetric changes of the aortic root and ascending aorta were quantified.

Results: Mean age was 64.6 ± 10.6 years. Indications for surgery using Freestyle prosthesis were combined aortic valve pathologies, aortic aneurysm or dissection, and endocarditis, with concomitant surgery occurring in 28 out of 32 patients. In-hospital mortality was 18.6%. Preoperative diameter and area measurements of the aortic annulus strongly correlated with the implanted valve size (p < 0.001). Bicuspid valve was present in 28.1% of the patients. Diameter and areas of the aortic root decreased after freestyle implantation, resulting in a reduction of the aortic root volume (45.6 ± 26.3 cm to 18.7 ± 4.5 cm, p = 0.029). Volume of the aortic root and the ascending aorta decreased from 137.3 ± 65.2 cm to 54.5 ± 21.1 cm after Freestyle implantation (p = 0.023).

Conclusion: Implantation of the Freestyle prosthesis presents excellent results in restoring the aortic geometry. Preoperative CTA measurements are beneficial to the surgical procedure and valve selection and therefore, if available, should be considered in pre-operative planning.
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http://dx.doi.org/10.1186/s13019-021-01583-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8320201PMC
July 2021

Sutureless aortic valve replacement in multivalve procedures.

J Thorac Dis 2021 Jun;13(6):3392-3398

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.

Background: Despite the rapid expansion of transcatheter approaches for aortic valve implantation, surgical aortic valve replacement remains the treatment of choice in patients presenting with multiple valvular heart disease. We sought to review our clinical experience with sutureless aortic valve replacement (SU-AVR) in the setting of multivalve procedures, addressing the postoperative outcomes and technical challenges.

Methods: Between December 2019 and December 2020, 20 consecutive high-risk patients at our institution underwent SU-AVR and concomitant mitral valve procedure for various indications.

Results: The mean age of the patients at operation was 72.6±9.3 years. Fifty five percent of the patients (n=11) presented with moderate to severe symptomatic aortic valve stenosis, while 35% (n=7) suffered from severe aortic regurgitation. All patients had concomitant moderate to severe mitral valve disease, including regurgitation in 95% (n=19) and stenosis in 25% (n=5). Mean logistic EuroSCORE was 34.3%±24.7%. Cardiopulmonary bypass and cross-clamp times were 101 (88.0-123) minutes and 67.5 (51.7-85.2) minutes, respectively. Optimal sutureless aortic valve prosthesis device success was achieved in 20 patients (100%). One patient (5%) required permanent pacemaker implantation. Thirty-day mortality was 10% and no strokes were detected.

Conclusions: SU-AVR is a safe and feasible surgical alternative to conventional procedures in patients presenting with multiple valvular heart disease. It provides excellent hemodynamic performance with low risk of paravalvular leakage and low transvalvular gradients, whilst simplifying the surgical procedure. Precise sizing and positioning of the valve prostheses is crucial to ensure optimal postoperative outcome.
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http://dx.doi.org/10.21037/jtd-21-300DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8264712PMC
June 2021

Transit time flow measurement of coronary bypass grafts before and after protamine administration.

J Cardiothorac Surg 2021 Jul 9;16(1):195. Epub 2021 Jul 9.

Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY, USA.

Background: Intraoperative graft assessment with tools like Transit Time Flow Measurement (TTFM) is imperative for quality control in coronary surgery. We investigated the variation of TTFM parameters before and after protamine administration to identify new benchmark parameters for graft quality assessment.

Methods: The database of the REQUEST ("REgistry for QUality AssESsmenT with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery") study was retrospectively reviewed. A per graft analysis was performed. Only single grafts (i.e., no sequential nor composite grafts) where both pre- and post-protamine TTFM values were recorded with an acoustical coupling index > 30% were included. Grafts with incomplete data and mixed grafts (arterio-venous) were excluded. A second analysis was performed including single grafts only in the same MAP range pre- and post- protamine administration.

Results: After adjusting for MAP, we found a small increase in MGF (29 mL/min to 30 mL/min, p = 0.009) and decrease in PI (2.3 to 2.2, p <  0.001) were observed after the administration of protamine. These changes were especially notable for venous conduits and for CABG procedures performed on-pump.

Conclusion: The small changes in TTFM parameters observed before and after protamine administration seem to be clinically irrelevant, despite being statistically significant in aggregate. Our data do not support a need to perform TTFM measurements both before and after protamine administration. A single TTFM measurement taken either before or after protamine may suffice to achieve reliable data on each graft's performance. Depending on the specific clinical situation and intraoperative changes, more measurements may be informative.

Trial Registration: Clinical Trials Number: NCT02385344 , registered February 17th, 2015.
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http://dx.doi.org/10.1186/s13019-021-01575-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8268198PMC
July 2021

Surgical redo mitral valve replacement in high-risk patients: The real-world experience.

J Card Surg 2021 Sep 5;36(9):3195-3204. Epub 2021 Jul 5.

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.

Introduction: Redo surgical mitral valve replacement (SMVR) remains the gold standard treatment in patients with a history of mitral valve surgery presenting with recurrent mitral valve pathologies. Whilst this procedure is demanding, it is an inevitable intervention for some indications, such as infective endocarditis, thrombosis, or multivalve procedures. In this study, we aim to evaluate our institutional experience with SMVR on a real-life cohort, identifying the factors that contribute to poor surgical outcomes whilst avoiding selection bias.

Methods: Between March 2012 and November 2020, 58 consecutive high-risk patients underwent a redo SMVR at our institution. The primary endpoints of this study were 30-day and 1-year mortality. The secondary endpoint was the development of any postoperative adverse events. We analyzed and compared the survival in patients undergoing an isolated SMVR and in those that required at least one concomitant procedure.

Results: The overall operative, 30-day, and 1-year mortality were 3.4%, 22.4%, and 25.9%, respectively. The mortality in patients undergoing isolated SMVR was significantly lower than in patients requiring concomitant procedures. The multivariable regression model showed that NYHA Class IV, infective endocarditis, and postoperative dialysis were significantly associated with 30-day mortality. Society of Thoracic Surgeons Score, infective endocarditis, concomitant procedures, and mechanical valve implantation appeared to predict long-term mortality.

Conclusion: This study illustrates that SMVR after prior mitral valve surgery presents a demanding procedure with high operative risk, significant mortality, and morbidity. Whilst this procedure is inevitable for some indications, a careful patient selection and risk stratification provides acceptable surgical results in this cohort.
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http://dx.doi.org/10.1111/jocs.15787DOI Listing
September 2021

Intraoperative transit-time flow measurement and high-frequency ultrasound in coronary artery bypass grafting: impact in off versus on-pump, arterial versus venous grafting and cardiac territory grafted.

Eur J Cardiothorac Surg 2021 Jun 24. Epub 2021 Jun 24.

Department of Cardiac Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.

Objectives: Despite society guideline recommendations, intraoperative high-frequency ultrasound (HFUS) and transit-time flow measurement (TTFM) use in coronary artery bypass grafting (CABG) has not been widely adopted worldwide. This retrospective review of the REQUEST (REgistry for QUality assESsmenT with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery) study assesses the impact of protocolled high-frequency ultrasound/TTFM use in specific technical circumstances of CABG.

Methods: Three REQUEST study sub-analyses were examined: (i) For off-pump (OPCAB) versus on-pump (ONCAB) procedures: strategy changes from preoperative plans for the aorta, conduits, coronary targets and graft revisions; and for all REQUEST patients, revision rates in: (ii) arterial versus venous grafts; and (iii) grafts to different cardiac territories.

Results: Four hundred and two (39.6%) of 1016 patients undergoing elective isolated CABG for multivessel disease underwent OPCAB procedures. Compared to ONCAB, OPCAB patients experienced more strategy changes regarding the aorta [14.7% vs 3.4%; odds ratios (OR) = 4.03; confidence interval (CI) = 2.32-7.20], less regarding conduits (0.2% vs 2.8%; OR = 0.09; CI = 0.01-0.56), with no differences in coronary target changes or graft revisions (4.1% vs 3.5%; OR = 1.19; CI = 0.78-1.81). In all REQUEST patients, revisions were more common for arterial versus venous grafts (4.7% vs 2.4%; OR = 2.05; CI = 1.29-3.37), and inferior versus anterior (5.1% vs 2.9%; OR = 1.77; CI = 1.08-2.89) and lateral (5.1% vs 2.8%; OR = 1.83; CI = 1.04-3.27) territory grafts.

Conclusions: High-frequency ultrasound/TTFM use differentially impacts strategy changes and graft revision rates in different technical circumstances of CABG. Notably, patients undergoing OPCAB experienced 4 times more changes related to the ascending aorta than ONCAB patients. These findings may indicate where intraoperative assessment is most usefully applied.

Clinical Trial Registration Number: ClinicalTrials.gov: NCT02385344.
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http://dx.doi.org/10.1093/ejcts/ezab239DOI Listing
June 2021

Identifying therapeutic drug targets using bidirectional effect genes.

Nat Commun 2021 04 13;12(1):2224. Epub 2021 Apr 13.

BioMarin Pharmaceutical Inc., Novato, CA, USA.

Prioritizing genes for translation to therapeutics for common diseases has been challenging. Here, we propose an approach to identify drug targets with high probability of success by focusing on genes with both gain of function (GoF) and loss of function (LoF) mutations associated with opposing effects on phenotype (Bidirectional Effect Selected Targets, BEST). We find 98 BEST genes for a variety of indications. Drugs targeting those genes are 3.8-fold more likely to be approved than non-BEST genes. We focus on five genes (IGF1R, NPPC, NPR2, FGFR3, and SHOX) with evidence for bidirectional effects on stature. Rare protein-altering variants in those genes result in significantly increased risk for idiopathic short stature (ISS) (OR = 2.75, p = 3.99 × 10). Finally, using functional experiments, we demonstrate that adding an exogenous CNP analog (encoded by NPPC) rescues the phenotype, thus validating its potential as a therapeutic treatment for ISS. Our results show the value of looking for bidirectional effects to identify and validate drug targets.
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http://dx.doi.org/10.1038/s41467-021-21843-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8044152PMC
April 2021

Impact of gender in patients with continuous-flow left ventricular assist device therapy in end-stage heart failure.

Int J Artif Organs 2021 03 30:3913988211006715. Epub 2021 Mar 30.

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.

Background: There is an ongoing debate about the influence of the female gender on postoperative outcomes after durable left ventricular assist device (LVAD) implantation. Despite the differences in pathophysiology of heart failure in females, therapy concepts are the same as in the male population. The aim of this study was to investigate the role of the female gender in surgical heart failure therapy.

Materials And Methods: Between August 2010 and January 2020, 207 patients were treated with durable LVAD at out institution. We matched 111 patients in two groups to compare the outcomes in male and female patients and to stratify the risk factors of mortality.

Results: The groups were matched 2:1 and were comparable after matching. We found no difference in in-hospital and follow-up mortality between male and female patients. Postoperative adverse events and complications were found to be unvaried across male and female patients. Female patients had higher rates of postoperative LVAD-thrombosis compared to their male counterparts (13.5% vs 0,  = 0.001) and the rates of renal replacement therapy lasting over 90 days were also higher in the female group (33.8% vs 56.8%,  = 0.021). Furthermore, the female gender was not an independent predictor neither of in-hospital nor follow-up mortality.

Conclusions: Durable continuous flow left ventricular assist devices as a bridge to transplantation or recovery in female patients are associated with a higher risk of acute kidney injury requiring RRT and are at a higher risk of LVAD-thrombosis. Nevertheless, survival rates between genders are similar.
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http://dx.doi.org/10.1177/03913988211006715DOI Listing
March 2021

Impact of pre-existing comorbidities on outcomes of patients undergoing surgical aortic valve replacement - rationale and design of the international IMPACT registry.

J Cardiothorac Surg 2021 Mar 25;16(1):51. Epub 2021 Mar 25.

Kepler University Hospital Linz, Linz; and Hospital Wels-Grieskirchen, Wels, Austria.

Background: Degenerative aortic valve disease accounts for 10-20% of all cardiac surgical procedures. The impact of pre-existing comorbidities on the outcome of patients undergoing surgical aortic valve replacement (SAVR) needs further research.

Methods: The IMPACT registry is a non-interventional, prospective, open-label, multicenter, international registry with a follow-up of 5 years to assess the impact of pre-existing comorbidities of patients undergoing SAVR with the INSPIRIS RESILIA aortic valve on outcomes. IMPACT will be conducted across 25 sites in Austria, Germany, The Netherlands and Switzerland and intends to enroll approximately 500 patients. Patients will be included if they are at least 18 years of age and are scheduled to undergo SAVR with the INSPIRIS RESILIA Aortic Valve with or without concomitant ascending aortic root replacement and/or coronary bypass surgery. The primary objective is to determine all-cause mortality at 1, 3, and 5 years post SAVR. Secondary objectives include cardiac-related and valve-related mortality and structural valve deterioration including hemodynamics and durability, valve performance and further clinical outcomes in the overall study population and in specific patient subgroups characterized by the presence of chronic kidney disease, hypertension, metabolic syndrome and/or chronic inflammation.

Discussion: IMPACT is a prospective, multicenter European registry, which will provide much-needed data on the impact of pre-existing comorbidities on patient outcomes and prosthetic valve performance, and in particular the performance of the INSPIRIS RESILIA, in a real-world setting. The findings of this study may help to support and expand appropriate patient selection for treatment with bioprostheses.

Trial Registration: ClinicalTrials.gov identifier: NCT04053088 .
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http://dx.doi.org/10.1186/s13019-021-01434-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7993500PMC
March 2021

Intraoperative surgical strategy changes in patients with chronic and end-stage renal disease undergoing coronary artery bypass grafting.

Eur J Cardiothorac Surg 2021 06;59(6):1210-1217

Department of Cardiac Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.

Objectives: Factors such as more diffuse atherosclerosis, plaque instability and accelerated vascular calcification in patients with chronic and end-stage renal disease (ESRD) can potentially present intraoperative challenges in coronary artery bypass grafting (CABG) procedures. We evaluated whether patients with chronic and ESRD experienced more surgical strategy changes and/or graft revisions than patients with normal renal function when undergoing CABG procedures according to a protocol for intraoperative high-frequency ultrasound and transit-time flow measurement (TTFM).

Methods: Outcomes of CABG for patients with chronic and ESRD and patients with normal renal function enrolled in the multicentre prospective REQUEST (REgistry for QUality assESsmenT with Ultrasound Imaging and TTFM in Cardiac Bypass Surgery) study were compared retrospectively. The primary end point was frequency of intraoperative surgical strategy changes. The secondary end point was post-protamine TTFM parameters.

Results: There were 95 patients with chronic and ESRD and 921 patients with normal renal function. Patients with chronic and ESRD undergoing CABG according to a protocol for intraoperative high-frequency ultrasound and TTFM had a higher rate of strategy changes overall [33.7% vs 24.3%; odds ratio (OR) = 1.58; 95% confidence interval (CI) = 1.01-2.48; P = 0.047] and greater revisions per graft (7.0% vs 3.4%; odds ratio = 2.14; 95% CI = 1.17-3.71; P = 0.008) compared to patients with normal renal function. Final post-protamine graft TTFM parameters were comparable between cohorts.

Conclusions: Patients with chronic and ESRD undergoing CABG procedures with high-frequency ultrasound and TTFM experience more surgical strategy changes than patients with normal renal function while achieving comparable graft flow.

Clinical Trial Registration Number: ClinicalTrials.gov NCT02385344.
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http://dx.doi.org/10.1093/ejcts/ezab104DOI Listing
June 2021

Open Transcatheter Multivalve Replacement in Degenerated Valve Prostheses in High-Risk Patients with Endocarditis.

Braz J Cardiovasc Surg 2021 Feb 1. Epub 2021 Feb 1.

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.

Multivalve redo procedures carry a high surgical risk. We describe an alternative surgical treatment for patients presenting with severely degenerated aortic and mitral valve prostheses who have to undergo open surgery due to endocarditis. Open transcatheter multivalve implantation is a feasible bailout strategy in high-risk patients to save cross-clamp and procedural times to reduce morbidity and mortality.
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http://dx.doi.org/10.21470/1678-9741-2020-0394DOI Listing
February 2021

Step-by-Step Minimally Invasive Aortic Valve Replacement: the RAT Approach.

Braz J Cardiovasc Surg 2021 Jun 1;36(3):420-423. Epub 2021 Jun 1.

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.

In the growing era of transcatheter aortic valve implantation, it is crucial to develop minimally invasive surgical techniques. These methods enable easier recovery from surgical trauma, especially in elderly and frail patients. Minimally invasive aortic valve replacement (MIAVR) is frequently performed via upper hemisternotomy. We describe MIAVR via right anterior thoracotomy, which is associated with less trauma, rapid mobilization, lower blood transfusion rates, and lower risk of postoperative wound infections. As minimally invasive procedures tend to take longer operative times, we suggest using rapid-deployment valve prostheses to overcome this limitation. This description focuses on the technical aspects and preoperative assessment.
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http://dx.doi.org/10.21470/1678-9741-2020-0393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8357396PMC
June 2021

Extracorporeal cytokine adsorption: Significant reduction of catecholamine requirement in patients with AKI and septic shock after cardiac surgery.

PLoS One 2021 8;16(2):e0246299. Epub 2021 Feb 8.

Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany.

Background: Extracorporeal cytokine adsorption is an option in septic shock as an additional measure to treat a pathological immune response. Purpose of this study was to investigate the effects of extracorporeal cytokine adsorption on hemodynamic parameters in patients with acute kidney injury (AKI) on continuous renal replacement therapy (CRRT) and septic shock after cardiac surgery.

Methods: In this retrospective study, a total of 98 patients were evaluated. Hemoadsorption was performed by the CytoSorb® adsorber. In all patients cytokine adsorption was applied for at least 15 hours and at least one adsorber was used per patient. To compare cumulative inotrope need in order to maintain a mean arterial pressure (MAP) of ≥ 65 mmHg, we applied vasoactive score (VAS) for each patient before and after cytokine adsorption. A paired t-test has been performed to determine statistical significance.

Results: Before cytokine adsorption the mean VAS was 56.7 points. This was statistically significant decreased after cytokine adsorption (27.7 points, p< 0.0001). Before cytokine adsorption, the mean noradrenalin dose to reach a MAP of ≥ 65 mmHg was 0.49 μg/kg bw/min, the mean adrenalin dose was 0.12 μg/kg bw/min. After cytokine adsorption, significantly reduced catecholamine doses were necessary to maintain a MAP of ≥ 65 mmHg (0.24 μg/kg bw/min noradrenalin; p< 0.0001 and 0.07 μg/kg bw/min adrenalin; p < 0.0001). Moreover, there was a significant reduction of serum lactate levels after treatment (p< 0.0001). The mean SOFA-score for these patients with septic shock and AKI before cytokine adsorption was 16.7 points, the mean APACHE II-score was 30.2 points. The mean predicted in-hospital mortality rate based on this SOFA-score of 16.7 points was 77,0%, respectively 73,0% on APACHE II-score, while the all-cause in-hospital mortality rate of the patients in this study was 59.2%.

Conclusion: In patients with septic shock and AKI undergoing cardiac surgery, extracorporeal cytokine adsorption could significantly lower the need for postoperative inotropes. Additionally, observed versus SOFA- and APACHE II-score predicted in-hospital mortality rate was decreased.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0246299PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7870055PMC
July 2021

Simultaneous transaortic transcatheter aortic valve implantation and off-pump coronary artery bypass: An effective hybrid approach.

J Card Surg 2021 Apr 24;36(4):1226-1231. Epub 2021 Jan 24.

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.

Introduction: Transcatheter aortic valve implantation (TAVI) techniques are increasingly being adopted into clinical routine for various risk groups. Coronary artery disease (CAD) is seen in up to 75% of patients with severe aortic valve stenosis (AS) presenting with typical angina pectoris. Due to high mortality rates and procedural complications in these patients, a hybrid concept of simultaneous transaortic TAVI and off-pump coronary artery bypass (OPCAB) can be a feasible treatment option.

Methods: Between April 2014 and July 2020, 10 consecutive high-risk patients underwent concomitant transaortic TAVI and OPCAB at our institution. All indications were discussed in Heart Team and decisions were made based on patients' comorbidities and complexity of CAD. The study endpoints were 30-day mortality, device success, and development of postoperative adverse events defined by the Valve Academic Research Consorium.

Results: The mean age of the patients was 77.9 ± 7.1 years old. All patients presented with multiple comorbidities (mean logistic EuroSCORE 26.5 ± 12.3%, median EuroSCORE II 5.13% [interquartile range 4.2-9.5], mean STS-Score 6.04 ± 1.6%). Five patients (50%) presented with porcelain aorta. No conversion to conventional procedures was needed. 30-day mortality occurred in one patient (10%). Complete revascularization was achieved in seven (70%) of the patients. Device success rate was 100%. No paravalvular leakage was detected. No stroke, myocardial infarction or vascular complications were observed.

Conclusions: A hybrid approach combining transaortic TAVI and OPCAB might be a safe and feasible method of treatment in high-risk patients presenting with severe AS and CAD who are not eligible for conventional surgical or interventional solutions.
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http://dx.doi.org/10.1111/jocs.15351DOI Listing
April 2021

Outcomes of left ventricular assist device implantation for advanced heart failure in critically ill patients (INTERMACS 1 and 2): A retrospective study.

Artif Organs 2021 Jul 1;45(7):706-716. Epub 2021 Feb 1.

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany.

The use of left ventricular assist devices (LVADs) for advanced heart failure is becoming increasingly common. However, optimal timing and patient selection remain controversial. The aim of this study was to investigate outcomes of LVAD implantation for advanced heart failure in critically ill patients (INTERMACS 1 and 2). Between August 2010 and January 2020, 207 consecutive patients underwent LVAD implantation. Overall survival, major adverse events, and laboratory parameters were compared between patients in INTERMACS 1-2 (n = 107) and INTERMACS 3-5 (n = 100). Preoperative white blood cells, C-reactive protein, procalcitonin, bilirubin, alanine transaminase, and lactate dehydrogenase were all significantly higher in INTERMACS 1-2 when compared to INTERMACS 3-5 (P < .05). During hospitalization following LVAD implantation, patients in INTERMACS 1-2 were more likely to develop major infections (41.1% vs. 23.0%, P = .005), respiratory failure (57.9% vs. 25.0%, P < .001), mild (20.6% vs. 8.0%, P = .010), and moderate (31.8% vs. 7.0%, P < .001) right heart failure, and acute renal dysfunction (56.1% vs. 6.0%, P < .001). During a median follow-up of 2.00 years (interquartile range (IQR) 0.24-3.39 years), they had a higher incidence of thoracic (15.9% vs. 4.0%, P = .005) and gastrointestinal bleeding (21.5% vs. 11.0%, P = .042), as well as right heart failure (18.7% vs. 1%, P < .001). Risk of death was significantly higher in the INTERMACS 1-2 group (hazards ratio (HR) 1.64, 95% CI 1.12-2.40, P = .011). LVAD implantation in critically ill patients is associated with increased morbidity and mortality. Our results suggest that decision for LVAD should be not be delayed until INTERMACS 1 and 2 levels whenever possible.
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http://dx.doi.org/10.1111/aor.13897DOI Listing
July 2021

On-pump versus off-pump coronary artery bypass surgery for multi-vessel coronary revascularization.

J Thorac Dis 2020 Oct;12(10):5639-5646

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.

Background: This study aims to compare the operative and postoperative results of on-pump (ONCAB) and off-pump (OPCAB) coronary artery bypass surgery (CABG) for multi-vessel coronary revascularization (≥4 anastomoses).

Methods: From May 2018 to August 2019, a total of 120 patients (22.5% women, mean age 61.5±8.4 years) received either ONCAB (Group 1, n=60) or OPCAB (Group 2, n=60) for multi-vessel coronary artery disease (CAD). Preoperative left ventricular (LV) ejection fraction (EF) was 53.1%±8.4%. Median EuroSCORE II was 1.59 (interquartile range, 1.01-2.54). The median number of performed coronary anastomoses was 4 (interquartile range, 4-5), with equal distribution in both groups (P=0.4). All procedures were performed by highly experienced surgeons. The primary endpoints were overall survival at 30 days and freedom from severe adverse events (SAE), which included myocardial infarction (MI), coronary artery re-operation, and re-thoracotomy, caused by bleeding and stroke.

Results: The overall survival in both groups was 100% with no intraoperative OPCAB-to-on-pump conversion. The median procedure time was 169 min (interquartile range, 150-179 min) for Group 1 and 183 min (interquartile range, 169-205 min) for Group 2 (P<0.001). The overall freedom from SAE numbered 93.3% (98.3% 88.3%, P=0.030). Postoperative MI rate was 2.5% (n=3) with no significant difference for either group (0 5.0%, P=0.100). One MI patient underwent a re-operation, and two other patients received a conservative treatment. A total of 2.5% (n=3) of patients underwent a re-thoracotomy on account of bleeding (0 5.0%, P=0.100); no anastomosis-related bleeding was detected. Blood transfusion was applied in 31.7% of patients (38.3% 25.0%, P=0.090). A total of 1.7% of patients (1.7% 1.7%, P=0.800) developed a stroke. Ventilation time, intensive care unit stay, and hospital stay were similar in both groups.

Conclusions: ONCAB showed superior freedom from SAE and shorter procedure times when compared to OPCAB for multi-vessel coronary artery revascularization.
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http://dx.doi.org/10.21037/jtd-20-1284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7656392PMC
October 2020

Tricuspid valve repair in isolated tricuspid pathology: a 12-year single center experience.

J Cardiothorac Surg 2020 Nov 16;15(1):330. Epub 2020 Nov 16.

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.

Objectives: Long-term data on isolated surgical tricuspid valve procedures is limited. Current guidelines on heart valve disease recommend valve repair over valve replacement. In this study we report our 12-year single-center experience with isolated surgical tricuspid valve repair in patients with various tricuspid valve pathologies.

Methods: Between May 2007 and December 2019, 26 consecutive patients underwent isolated tricuspid valve annuloplasty/repair for various indications. In 18 patients (69.2%) an open ring or band annuloplasty (26.9 and 42.3%, respectively) was performed, 5 patients (19.2%) underwent a tightening of the annulus using the DeVega technique, 5 patients (19.2%) had a leaflet reconstruction with patch or bicuspidalization and in 3 patients (11.5%) a leaflet debridement was performed. In 15.4% of the cohort a combination of the techniques was utilized.

Results: The mean follow-up time was 2.1 (0.3-5.0) years. Early survival at 30 days after surgery was 84.6%. Mean hospital stay was 11 (6.7-16) days. One-year survival was 73%. No patient required a redo procedure on the tricuspid valve during follow-up.

Conclusion: Tricuspid valve repair is suggested as a treatment of choice according to recent guidelines on heart valve disease. If chosen correctly, various repair techniques provide good long-term results. Tricuspid valve repair may be safely applied in patients undergoing surgical isolated tricuspid valve procedures.
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http://dx.doi.org/10.1186/s13019-020-01369-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670779PMC
November 2020

The Impact of Obesity on Left Ventricular Assist Device Outcomes.

Medicina (Kaunas) 2020 Oct 23;56(11). Epub 2020 Oct 23.

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, 45122 Essen, Germany.

: The understanding of high body mass index (BMI) and outcomes after Left Ventricular Assist Device (LVAD) implantation continues to evolve and the relationship has not been established yet. In this study, we investigated the effects of obesity (BMI > 30 kg/m) on post-LVAD implantation outcomes. HeartWare LVAD and Heart Mate III LVAD were implanted. The primary outcome that was measured was mortality (in-hospital and on follow-up). The secondary outcomes that were measured were major adverse events. At our institution, the West German Heart and Vascular Center (Essen, Germany), from August 2010 to January 2020, a total of 210 patients received a long-term LVAD. Patients were stratified according to BMI ≥ 30 kg/m representing the obesity threshold. The first group ( = 162) had an average BMI of 24.2 kg/m (±2.9), and the second group ( = 48) had an average BMI of 33.9 kg/m (±3.2). Baseline demographics were analysed alongside comorbidities per group. Overall mortality was not significantly different between the obese group (51.1% = 24) and the nonobese group (55.2%, = 85) ( = 0.619). The difference between the mean duration of survival of patients who expired after hospital discharge was insignificant (2.1 years ± 1.6, group 1; 2.6 years ± 1.5, group 2; = 0.29). In-hospital mortality was unvaried between the two groups: group 1: = 34 (44% out of overall group 1 deaths); group 2: = 11 (45.8% out of overall group 2 deaths) ( > 0.05). Postoperative complications were unvaried between the obese and the non-obese group (all with > 0.05). However, a significant difference was found with regards to follow-up neurological complications (18.5% vs. 37.8%, = 0.01) and LVAD thrombosis (14.7% vs. 33.3%, = 0.01), as both were higher in the obese population. Obesity does not form a barrier for LVAD implantation in terms of mortality (in-hospital and on follow up). However, a significantly higher incidence of follow-up LVAD thrombosis and neurological complications has been found in the obese group of patients.
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http://dx.doi.org/10.3390/medicina56110556DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7690722PMC
October 2020

Essen-Commando: How we do it.

J Card Surg 2021 Jan 21;36(1):286-289. Epub 2020 Oct 21.

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.

In rare cases of extensive aortic root or mitral valve infective endocarditis (IE), severe calcification of the aortic and mitral valves, or double-valve procedures in patients with small aortic and mitral annuli, surgical reconstruction of the intervalvular fibrous body (IVFB) is required. A high mortality is generally associated with this procedure, and it is frequently avoided by surgeons due to a lack of experience. It is crucial to radically resect all tissues that are severely affected by IE to prevent recurrence in the patient. Our experience with the Commando procedure in patients with extensive double-valve IE involving the IVFB is presented in this article.
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http://dx.doi.org/10.1111/jocs.15140DOI Listing
January 2021

Surgical revascularization for acute coronary syndromes: a report from the North Rhine-Westphalia surgical myocardial infarction registry.

Eur J Cardiothorac Surg 2020 12;58(6):1137-1144

Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.

Objectives: The aim of this was to analyse current outcomes in patients referred to coronary artery bypass grafting (CABG) for acute coronary syndromes (ACSs), including ST-elevation or non-ST-elevation ACS (non-ST-segment elevation myocardial infarction) or unstable angina.

Methods: Patients (n = 2432) undergoing CABG for ACS between January 2010 and December 2017 were prospectively entered into a surgical myocardial infarction registry in North Rhine-Westphalia, Germany. Key end points were in-hospital all-cause mortality (IHM) and major adverse cardio-cerebral events (MACCE). Predictors for IHM and MACCE were analysed by multivariable logistic regression.

Results: Patients (78% males) were referred for CABG for unstable angina (25%), non-ST-segment elevation myocardial infarction (50%), and ST-segment elevation myocardial infarction (25%). The mean patient age was 68 ± 11 years, logistic EuroSCORE was 19 ± 18% and three-vessel and left main stem diseases were diagnosed in 81% and 45% of patients, respectively. On-pump CABG with cardiac arrest or beating heart was performed in 92% and 2%, respectively, with only 6% off-pump surgery and 6% multiple arterial revascularization (3.1 ± 1.0 grafts, 93% left internal thoracic artery). Emergency CABG was performed in 23% of patients (42% in ST-segment elevation myocardial infarction; P < 0.001). The total IHM and MACCE rates were 8.1% and 17.5% and were highest in ST-segment elevation myocardial infarction patients with 12.6% and 28.5%, respectively (P < 0.001). Key predictors for IHM and MACCE were female gender, elevated troponin, left ventricular ejection fraction, inotropic support, logistic EuroSCORE, cardiopulmonary bypass and aortic clamp time and the need for emergency CABG.

Conclusions: Surgical myocardial revascularization in patients with ACS is still linked to substantial in-hospital mortality. Emergency CABG for patients with ACS was associated with poorer outcomes.
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http://dx.doi.org/10.1093/ejcts/ezaa260DOI Listing
December 2020

Outcomes and hemodynamics of Enable bioprosthesis in 432 patients: an afterword.

Minim Invasive Ther Allied Technol 2020 Jul 14:1-6. Epub 2020 Jul 14.

Department of Cardiac Surgery, European Medical School Oldenburg-Groningen, Carl von Ossietzky University Oldenburg, Oldenburg, Germany.

Aims: To report the largest single-center experience in surgical aortic valve replacement (SAVR) using the Enable sutureless bioprosthesis concerning the clinical outcome and hemodynamic behavior.

Material And Methods: From April 2010 to May 2017, a total of 432 patients (36.3% of them women) received the Enable sutureless prosthesis for aortic valve stenosis, regurgitation, and/or endocarditis. The endpoints were overall survival after operation for 30 days and adverse events.

Results: No intraoperative complications occurred; intraoperative mortality was 0%. The 30-day mortality rate was 3.5% overall and 0.9% for isolated procedure. No valve-related deaths were observed. There was a need for prosthesis replacement during the early postoperative period in eight patients (1.9%): seven patients (1.6%) had a significant paravalvular leak and one patient (0.2%) developed early postoperative endocarditis. The maximum and mean pressure gradients across the prosthesis were 19.2 ± 7.1 mmHg and 11.1 ± 4.6 mmHg, respectively. A permanent pacemaker was necessary in 6.5% of the patients.

Conclusions: The Enable sutureless prosthesis showed a reliable clinical outcome with low perioperative mortality and morbidity. The hemodynamic performance was satisfactory. Our data confirmed the safety of SAVR using the Enable bioprosthesis. However, a higher rate of pacemaker implantation (6.5%) has to be mentioned.
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http://dx.doi.org/10.1080/13645706.2020.1785894DOI Listing
July 2020

New 3-zone hybrid graft: First-in-man experience in acute type I dissection.

J Thorac Cardiovasc Surg 2020 May 6. Epub 2020 May 6.

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital Essen, Essen, Germany.

Objective: Acute type I aortic dissection (AAD) represents a surgical emergency with time-dependent evolving complications. Frozen elephant trunk (FET) enables false lumen exclusion downstream but is still debated in AAD due to its greater dimension of surgery. To combine the benefits of fast proximal repair with the FET benefits, a 3-zone hybrid graft was developed consisting of an ascending polyester portion, an arch noncovered stent, and a descending stent graft. Mid-term results of this new technique are presented.

Methods: A total of 6 patients (age mean 69 years) with type I AAD in critical status (Penn classification B n = 5, BC n = 1) were operated between July 2016 and April 2018 using the 3-zone hybrid graft. The device was implanted on the basis of strict compassionate use. Operations were performed under distal hypothermic circulatory arrest and selective antegrade cerebral perfusion (SACP).

Results: Operative mortality was 17% (n = 1). Mean crossclamp and SACP time were 92 and 34 minutes, respectively, but came down in the last 2 cases to 75/65 crossclamp and 23/24 SACP minutes each. During follow up, mean 19 ± 12 months, one endovascular extension downstream was performed. Imaging control demonstrated no anastomotic-related proximal entry and no true lumen collapse downstream.

Conclusions: The goal to achieve fast and reliable repair of complicated type I AAD down to midthoracic level seems to be achievable. Noncovered stenting of the head vessel's origin does not cause stenosis or obstruction. A multicenter studying of this concept is next.
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http://dx.doi.org/10.1016/j.jtcvs.2020.04.113DOI Listing
May 2020

Intraoperative Hemoadsorption Therapy Can Be Beneficial in Patients With Infective Endocarditis: Reply.

Ann Thorac Surg 2020 12 22;110(6):2106-2107. Epub 2020 Jun 22.

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center, University Hospital Essen, Hufelandstrasse 55, D-45147 Essen, Germany.

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http://dx.doi.org/10.1016/j.athoracsur.2020.04.140DOI Listing
December 2020

A new simplified technique for artificial chordae implantation in mitral valve repair with its early results.

J Thorac Dis 2020 Mar;12(3):724-732

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Centre Essen, University Hospital Essen, Essen, Germany.

Background: Many techniques in mitral valve repair (MVR) have been reported with successful long-term results. The aim of this study is to present our simplified technique in artificial chordae replacement for MVR, and reporting its short-term outcomes.

Methods: We present a prospective single-surgeon experience. A new simplified artificial chordae implantation technique has been used to repair mitral valves. Postoperative echocardiography at 0, 6, then every 12 months is used to control the results. Endpoints involved freedom from mitral regurgitation (MR), reoperation and major adverse cardiac and cerebrovascular events (MACCE).

Results: Between 01/2016 and 01/2018, 57 consecutive patients undergo MVR using this technique are evaluated. Mean age was 63.6±10.1 years and 68.4% were male. Mitral valve pathology was mainly degenerative (52, 91.2%) or healed endocarditis (5, 8.8%). Besides chordae replacement (3.6±1.1 per patient), annuloplasty was used in all patients to correct annulus dilation and stabilize the repair. Mean cross-clamping time was 53±13.4 minutes in isolated MVR and 69.4±31.1 minutes in concomitant procedures. Postoperative outcomes reported two mortalities. Discharge echocardiography reported mild MR in 4 patients and the rest of patients had non-to trace regurgitation. Follow-up results within a mean of 19.3±8.5 months reported no significant MR or need for reoperation and three more (non-valve related) mortalities.

Conclusions: Our simplified technique allows to reduce the number of used chordae and re-correction if needed, which consequently reduces cross-clamping and bypass time especially in endoscopic MVR. Good intraoperative and short-term results are reported. These results are still under investigation to prove long-term stability of the repair.
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http://dx.doi.org/10.21037/jtd.2019.12.105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7138970PMC
March 2020

Surgical treatment of infective endocarditis in the era of minimally invasive cardiac surgery and transcatheter approach: an editorial.

J Thorac Dis 2020 Mar;12(3):140-142

Department of Thoracic and Cardiovascular Surgery, West German Heart and Vascular Center Essen, University Hospital of Essen, University Duisburg-Essen, Essen, Germany.

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http://dx.doi.org/10.21037/jtd.2020.01.59DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7139084PMC
March 2020

Impact of Bioprosthetic Choice on Mortality After Transfemoral Transcatheter Aortic Valve Implantation in Patients With Reduced Versus Preserved Left-Ventricular Ejection Fraction.

Am J Cardiol 2020 05 4;125(10):1550-1557. Epub 2020 Mar 4.

Faculty of Medicine, University Duisburg-Essen, Essen, Germany. Electronic address:

The outcome of transfemoral transcatheter aortic valve implantation (TF-TAVI) with a self-expanding (SEP) versus a balloon-expandable prosthesis (BEP) in patients with a reduced ejection fraction (rEF, ≤40%) has not been previously investigated. Patients with rEF have an increased risk of death after TF-TAVI compared to patients with a preserved ejection fraction (pEF), and prosthesis choice might influence the outcome of these patients. We, therefore, sought to compare all-cause mortality of patients with rEF using a SEP versus a BEP. We retrospectively analyzed data of 679 single-center TF-TAVI patients. Patients were censored at death or completion of 1-year follow-up, whichever occurred first. Patients with rEF (n = 141, 21%) had an increased 1-year mortality compared to patients with pEF (28% vs 19%, p = 0.007). SEP were implanted in 149 patients (49 with rEF, 33%), while BEP were implanted in 530 patients (92 with rEF, 17%). In patients with pEF, 1-year mortality was similar after SEP- and BEP-implantation (16% vs 19%, p = 0.516). In patients with rEF, however, 1-year mortality was higher after SEP- than after BEP-implantation (43% vs 21%, p = 0.004). These patients had a higher incidence of new permanent pacemaker implantation (26.5% vs 13%, p = 0.046) and paravalvular leak ≥II° (21% vs 10%, p = 0.07), but both factors could not explain the excess mortality after SEP-implantation in the multivariate analysis. In patients with rEF, the use of a SEP was an independent predictor of 1-year mortality (HR 2.44, 95% CI 1.27 to 4.27, p = 0.007). In conclusion, patients with rEF had a higher 1-year mortality after TF-TAVI when a SEP instead of a BEP was used.
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http://dx.doi.org/10.1016/j.amjcard.2020.02.022DOI Listing
May 2020

Intraoperative Hemoadsorption in Patients With Native Mitral Valve Infective Endocarditis.

Ann Thorac Surg 2020 09 12;110(3):890-896. Epub 2020 Feb 12.

Department of Thoracic and Cardiovascular Surgery, West-German Heart and Vascular Centre, University Hospital Essen, Essen, Germany.

Background: Cardiac surgery in patients with infective endocarditis is associated with high mortality owing to postoperative septic multiorgan failure. Hemoadsorption therapy may improve surgical outcomes by reducing the circulating cytokines. We aimed to evaluate the clinical effects of intraoperative hemoadsorption in patients with mitral valve endocarditis.

Methods: Eligible candidates were patients with infective endocarditis of the native mitral valve undergoing cardiac surgery between January 2014 and July 2018. Patients with intraoperative hemoadsorption (hemoadsorption) were compared with surgery without hemoadsorption (control). The end points were the incidence of postoperative sepsis, sepsis-associated death, and 30-day mortality. Furthermore, postoperative need for epinephrine and norepinephrine and systemic vascular resistance were evaluated.

Results: A total of 58 consecutive patients were included: 30 in the hemoadsorption group and 28 in the control group. Postoperative sepsis occurred in 5 patients in the hemoadsorption group and in 11 in the control group (P = .05). No sepsis-associated death occurred in the hemoadsorption group, whereas five septic patients in the control group died (P = .02). Thirty-day mortality was 10% in the hemoadsorption group versus 18% in the control group (P = .39). On intensive care unit admission, the cumulative need for epinephrine and norepinephrine was 0.15 versus 0.24 μg/kg body weight/min (P = .01) and the median systemic vascular resistance was 1413 versus 1010 dyn·s·cm (P = .02) in the hemoadsorption versus control group, respectively.

Conclusions: Intraoperative hemoadsorption might reduce the incidence of postoperative sepsis and sepsis-related death. In addition, patients with intraoperative hemoadsorption showed greater hemodynamic stability. These data suggest that intraoperative hemoadsorption may improve surgical outcome in patients with mitral valve endocarditis.
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http://dx.doi.org/10.1016/j.athoracsur.2019.12.067DOI Listing
September 2020

Intraoperative transit-time flow measurement and high-frequency ultrasound assessment in coronary artery bypass grafting.

J Thorac Cardiovasc Surg 2020 04 22;159(4):1283-1292.e2. Epub 2019 Aug 22.

Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Rotterdam, The Netherlands. Electronic address:

Objectives: We evaluated the influence of transit-time flow measurement with epicardial and epiaortic high-frequency ultrasound in patients undergoing coronary artery bypass grafting procedure.

Methods: The Registry for Quality Assessment with Ultrasound Imaging and Transit-time Flow Measurement in Cardiac Bypass Surgery study is a multicenter, prospective study among 7 international centers performing coronary artery bypass grafting procedures. The primary end point was any change in the planned surgical procedure. Major secondary end points consisted of the rate and reason for surgical changes related to the aorta, in situ conduits, coronary targets, and completed grafts, and the rate of in-hospital mortality and major morbidity.

Results: Between April 2015 and December 2017, 1046 patients were enrolled. Of those, 1016 were included in the final analyses. Mean age was 65.9 years, 14.0% were women, and diabetes was present in 39.6%. Off-pump procedures were performed in 39.6% and bilateral internal thoracic arteries in 30.5%. The primary end point occurred in 25.2% of patients (n = 256) and in 77% (197 out of 256) this was based on transit-time flow measurement and/or high-frequency ultrasound. Surgical changes were related to the aorta in 9.9%, to in situ conduits in 2.7%, and the coronary targets in 22.6%. Graft revision occurred in 7.8%, including revisions of the proximal and/or distal anastomosis in 6.6%. In-hospital adverse event rates were 0.6% for mortality, 1.0% for cerebrovascular events, and 0.3% for myocardial infarction.

Conclusions: Surgical changes related to the aorta, conduits, coronary targets, and anastomosis were made in 25% of patients. This was associated with low operative mortality and low major morbidity. Transit-time flow measurement and high-frequency ultrasound may improve the quality, safety, and efficacy of coronary artery bypass grafting procedures and should be considered as a routine procedural aspect.
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http://dx.doi.org/10.1016/j.jtcvs.2019.05.087DOI Listing
April 2020
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