Publications by authors named "Dominik Wiedemann"

138 Publications

Psoas Muscle Area Predicts Mortality after Left Ventricular Assist Device Implantation.

Life (Basel) 2021 Sep 5;11(9). Epub 2021 Sep 5.

Division of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria.

Several risk scores and classifications are available to predict peri- and post-operative mortality of patients with end stage heart failure receiving Left Ventricular Assist Device (LVAD) therapy. Sarcopenia has been suggested as a sensitive predictor for post-operative mortality. We evaluated whether the psoas muscle area can predict mortality in patients undergoing LVAD implantation. The indexed psoas mean area (PMAi) was obtained by measuring the psoas muscle area at the superior endplate of the third lumbar vertebra correlated to body surface area of 106 adult patients undergoing LVAD implantation (Medtronic HVAD = 41, Abbott HeartMate II = 4, Abbott HeartMate 3 = 61; mean age 65, IQR 12, 90.6% male; INTERMACS Level 1 24.5%; ischemic CMP 64.2%). Patients were divided in two groups: high/moderate and low muscle mass. The primary endpoint was 30-day mortality, assessed using a multivariate Cox proportional hazards model. Baseline characteristics did not differ between patients with high or moderate and low PMAi. Estimated survival calculated a significant higher 30-day mortality in patients with low PMAi ( = 0.04). Multivariable Cox proportional hazards regression analysis indicated low PMAi, history of previous cardiac surgery and levels of bilirubin as independent predictors of mortality in the first 30 days. In conclusion, indexed psoas muscle area predicts mortality after LVAD implantation and can be used as an additional tool for risk stratification.
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http://dx.doi.org/10.3390/life11090922DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8465376PMC
September 2021

Femoral cannulation for cardiopulmonary bypass with a novel bidirectional perfusion cannula.

Multimed Man Cardiothorac Surg 2021 08 17;2021. Epub 2021 Aug 17.

Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.

The use of the novel bidirectional femoral cannula is described in this video tutorial. We demonstrate the percutaneous cannulation and decannulation of the femoral artery for cardiopulmonary bypass in a patient undergoing minimally invasive mitral valve surgery. The procedure itself is presented step by step for each important phase. Finally, we report the postoperative course following the successful use of a peripheral bidirectional cannula.
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http://dx.doi.org/10.1510/mmcts.2021.047DOI Listing
August 2021

Incidence, clinical relevance and therapeutic options for outflow graft stenosis in patients with left ventricular assist devices.

Eur J Cardiothorac Surg 2021 Sep 1. Epub 2021 Sep 1.

Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.

Objectives: We reviewed our institutional experience with outflow graft stenosis (OGS) in 3 contemporary left ventricular assist devices (LVAD).

Methods: Data from 347 consecutive adult recipients of LVAD [Medtronic HVAD (n = 184, 53.0%), Abbott HeartMate II (n = 62, 17.9%) and Abbott HeartMate 3 (n = 101, 29.1%)] implanted between March 2006 and October 2019 were analysed retrospectively. Primary study end points were the incidence of OGS necessitating treatment and survival on LVAD support.

Results: During the study period, 17 patients (4.9%) developed OGS requiring treatment with a probability of 0.6% at 1 year, 1.9% at 2 years, 3.8% at 3 years, 4.7% at 4 years and 5.9% at 5 years of LVAD support. Notably, in 13.8% of patients, a compression-related narrowing of the outflow graft with a probability of 1.5% at 6 months, 1.8% 1 year, 6.0% at 2 years, 12.3% at 3 years, 15.4% at 4 years and 16.6% at 5 years of LVAD support with no difference between devices (P = 0.26) was observed. There was a trend towards increased risk of mortality with OGS (hazard ratio 2.21, 95% confidence interval 0.87-5.51; P = 0.09). OGS preferentially occurred in segments of the outflow graft covered by a protective coating.

Conclusions: OGS is a rare but potentially lethal complication during LVAD support. Modifications of pump design and implant techniques may be needed because OGS preferentially occurs within covered portions of the outflow graft. Systematic screening may be warranted.
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http://dx.doi.org/10.1093/ejcts/ezab382DOI Listing
September 2021

Hemadsorption as rescue therapy for patients with multisystem organ failure in pediatric intensive care-Report of two cases reports and review of the literature.

Artif Organs 2021 Jul 31. Epub 2021 Jul 31.

Division of Neonatology, Pediatric Intensive Care & Neuropediatrics, Department of Pediatric and Adolescent Medicine, Medical University of Vienna, Vienna, Austria.

Hemadsorption via the cytokine-adsorber CytoSorb (CytoSorbents Europe, Berlin, Germany) has successfully been used as an adjunctive method in adults, mainly for the purpose of immunomodulation under acute inflammatory conditions such as sepsis and cardiac surgery. In recent years, there has been growing interest in its use in pediatric intensive care to improve outcomes in patients with multiple organ failure following an inflammatory illness. Literature on the application of CytoSorb in neonatal and pediatric patients is scarce, though the implication is that it could be an effective last-resort treatment option in critically ill pediatric patients. Herein we present the clinical cases of two pediatric patients successfully treated with a combination of the CytoSorb hemadsorber, continuous renal replacement therapy, and extracorporeal membrane oxygenation due to multiple organ failure following different underlying medical conditions. Patient 1 was a 7-month-old male child with Down's syndrome admitted to the Pediatric Intensive Care Unit (PICU) after congenital heart surgery, who developed antimicrobial-resistant septic shock and severe acute respiratory distress syndrome. Patient 2 was a 2-year-old male child admitted to the PICU with influenza A-associated acute liver failure resulting in hyperammonemia, lactate acidosis, hemodynamic instability, and acute kidney failure. In both patients, hemadsorption with CytoSorb was initiated as an adjunctive rescue therapy to treat refractory multisystem organ failure. Improvement of laboratory and clinical parameters was observed within hours of treatment initiation. The application of the hemadsorber-developed for use in adults-proved simple and safe for use in both of our low-weight pediatric patients.
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http://dx.doi.org/10.1111/aor.14047DOI Listing
July 2021

Incidence and Etiology of System Exchanges in Patients Receiving Extracorporeal Membrane Oxygenation.

ASAIO J 2021 07;67(7):776-784

From the Department of Medicine I, Intensive Care Unit 13i2, Medical University of Vienna, Vienna, Austria.

Extracorporeal membrane oxygenation (ECMO) has established as a cornerstone therapy in severe acute respiratory distress syndrome and refractory hemodynamic failure. As circuit integrity is crucial for adequate organ support, component failure may necessitate a system exchange. In this retrospective study, incidence and etiology of system exchanges during applications of venovenous, venoarterial ECMO, and extracorporeal CO2 removal were examined. Sixty-three (44.4%) of 142 patients were affected by one or more exchanges, totaling 105 replaced circuits. The predominant exchange reason was clotting (n = 20), followed by hemolysis (n = 19), systemic coagulation disorders (n = 13), reconfiguration (n = 13), impaired gas exchange (n = 10), mechanical complications (n = 8), bleeding (n = 6), failed weaning (n = 5), prophylactic exchange (n = 3), and undocumented/other (n = 8). Nineteen (18.1%) events were classified as acute and 70 (66.7%) events as elective exchanges. Patients with circuit exchanges more frequently underwent renal replacement therapy at ECMO initiation (49.2% vs. 29.1%; p = 0.023), had a longer ECMO treatment duration (18 vs. 7.5 days, p < 0.001), and lower hospital survival (29.5% vs. 57.1%; p = 0.002). Considering the high occurrence of coagulation complications, further optimization of coagulation management is deemed necessary.
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http://dx.doi.org/10.1097/MAT.0000000000001332DOI Listing
July 2021

Impact of Venoarterial Extracorporeal Membrane Oxygenation on Alkaline Phosphatase Metabolism after Cardiac Surgery.

Biomolecules 2021 05 17;11(5). Epub 2021 May 17.

Department of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria.

(1) Alkaline phosphatase (AP) is consumed during cardiopulmonary bypass (CPB). A high AP depletion leads to an impaired outcome after cardiac surgery. However, data is scarce on the postoperative course of AP under venoarterial ECMO (VA-ECMO) support. (2) A total of 239 patients with VA-ECMO support between 2000 and 2019 at the Department of Cardiac Surgery (Vienna General Hospital, Austria) were included in this retrospective analysis. Blood samples were collected at several timepoints (baseline, postoperative day (POD) 1-7, POD 14 and 30). Patients were categorized according to the relative AP drop (<60% vs. ≥60%) and ECMO duration (<5 days vs. ≥5 days). (3) Overall, 44.4% reached the baseline AP values within 5 days-this was only the case for 28.6% with a higher AP drop (compared to 62.7% with a lower drop; = 0.000). A greater AP drop was associated with a significantly higher need for renal replacement therapy (40.9% vs. 61.9%; = 0.002) and an impaired 1-year survival (51.4% vs. 66.0%; = 0.031). (4) CPB exceeds the negative impact of VA-ECMO; still, ECMO seems to delay alkaline phosphatase recovery. A greater initial AP drop bears the risk of higher morbidity and mortality.
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http://dx.doi.org/10.3390/biom11050748DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8156119PMC
May 2021

The HeartMate 6 and CardioMEMS for Fixed Pulmonary Hypertension.

ASAIO J 2021 May 12. Epub 2021 May 12.

From the Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria Division of Cardiovascular and Interventional Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria Department of Internal Medicine 3, University Hospital St. Pölten Division of Cardiac Thoracic Vascular Anaesthesia and Intensive Care Medicine, Department of Anaesthesia, Intensive Care Medicine and Pain Medicine, Medical University of Vienna, Vienna, Austria.

Fixed pulmonary hypertension (FPH) is a contraindication for heart transplantation (HTX). However, this condition might be reversed by continuous left-ventricular unloading with a left-ventricular assist device. We present a case of apical hypertrophic cardiomyopathy with extensive left-ventricular endocardial calcification and severe FPH (systolic pulmonary artery pressure, 102 mm Hg). To bridge the patient to candidacy for HTX, two Abbott HeartMate 3 ventricular assist devices were implanted in a total artificial heart (TAH) configuration ("HeartMate 6"). Before TAH implantation, an Abbott CardioMEMS pressure sensor was implanted to assess reversal of FPH before listing for HTX.
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http://dx.doi.org/10.1097/MAT.0000000000001480DOI Listing
May 2021

Concomitant cardiac surgery procedures during left ventricular assist device implantation: single-centre experience.

Ann Cardiothorac Surg 2021 Mar;10(2):248-254

Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.

Background: Additional cardiac pathologies including tricuspid or mitral valve regurgitation are common in left ventricular assist device (LVAD) recipients and whether to address them remains controversial. We present our institutional outcomes of concomitant cardiac procedures, other than temporary right ventricular (RV) support, at the time of LVAD implantation.

Methods: From 03/2006 to 06/2020, 352 adult patients {median age 60 [interquartile range (IQR): 52-66] years; INTERMACS level 1 29%; INTERMACS level 2 17%; INTERMACS level 3 23%, INTERMACS level 4-6 31%; male 86%} underwent continuous-flow LVAD [Medtronic HVAD (HVAD) 50%; Abbott HeartMate II (HMII) 17%; Abbott HeartMate 3 (HM3) 33%] implantation. Concomitant valvular procedures were performed in 86 patients (24%) and the majority of patients received the LVAD as bridge to candidacy (BTC) for transplant (74%). Primary study endpoints were short- and mid-term mortality, as well as need for temporary RV support.

Results: Tricuspid valve annuloplasty was the most frequent concomitant procedure (77%), followed by aortic valve replacements (AVRs) or Park's stitch (33%). Temporary RV support was common in the study cohort (35%) using either extracorporeal life support (ECLS, 37%) or a temporary RV assist device (RVAD, 63%). A less invasive (LIS) implantation technique was pursued in 12%. Thirty-day mortality was comparable between those with and without concomitant surgery (4% 6%, P=0.426). In-hospital mortality was significantly higher for additional interventions (22% 14%, P=0.05), whereas one-year survival was similar (71% 79%, P=0.106).

Conclusions: Concomitant cardiac procedures, especially tricuspid and aortic valve surgery, are frequent but are associated with a higher perioperative morbidity and mortality.
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http://dx.doi.org/10.21037/acs-2020-cfmcs-30DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8033261PMC
March 2021

Ticagrelor or Aspirin After Coronary Artery Bypass in Patients With Chronic Kidney Disease.

Ann Thorac Surg 2021 Apr 2. Epub 2021 Apr 2.

German Heart Center Munich, Technical University of Munich, Munich, Germany; German Center for Cardiovascular Research, Munich Heart Alliance, Munich, Germany.

Background: The optimal antiplatelet therapy for patients with chronic kidney disease (CKD) undergoing coronary artery bypass graft surgery remains unknown.

Methods: This post hoc analysis of the Ticagrelor in Coronary Artery Bypass (TiCAB) trial examined the efficacy and safety of ticagrelor vs aspirin in patients with and patients without CKD. The primary endpoint was major adverse cardiac and cerebrovascular events (MACCE), namely, the composite of cardiovascular death, stroke, myocardial infarction, or revascularization at 1 year after coronary artery bypass graft surgery. Secondary endpoints included individual components of the primary endpoint, all-cause death, and major bleeding.

Results: Chronic kidney disease was present in 276 of 1843 randomized patients (15%). Patients with CKD vs patients without CKD had higher 1-year rates of MACCE (13% vs 8.3%, hazard ratio [HR] 1.63; 95% confidence interval [CI], 1.12 to 2.39; P = .01) and major bleeding (5.6% vs 3.1%, HR 1.84; 95% CI, 1.03 to 3.28; P = .04). The 1-year rate of MACCE was increased with ticagrelor vs aspirin in patients with CKD (18.2% vs 8.9%, HR 2.15; 95% CI, 1.08 to 4.30; P = .03), but not in patients without CKD (8.5% vs 8.1%, HR 1.05; 95% CI, 0.74 to 1.49; P = .79; P = .067). There was no difference in the 1-year rate of major bleeding with ticagrelor vs aspirin in patients with CKD (6.6% vs 4.7%, HR 1.44; 95% CI, 0.52 to 3.97; P = .48) and patients without CKD (3.3% vs 2.9%, HR 1.14; 95% CI, 0.64 to 2.01; P = .65).

Conclusions: Among patients with CKD and coronary artery bypass graft surgery, those who received ticagrelor had a higher incidence of MACCE but a similar incidence of major bleeding compared with those who received aspirin.
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http://dx.doi.org/10.1016/j.athoracsur.2021.03.061DOI Listing
April 2021

Platelet activation and aggregation in different centrifugal-flow left ventricular assist devices.

Platelets 2021 Mar 24:1-8. Epub 2021 Mar 24.

Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria.

Left-ventricular assist devices (LVADs) improve outcomes in end-stage heart failure patients. Two centrifugal-flow LVAD systems are currently approved, HeartMate 3 (HM3) and Medtronic/Heartware HVAD (HVAD). Clinical findings suggest differences in thrombogenicity between both systems. We compared markers of platelet activation and aggregation between HM3 and HVAD. We prospectively included 59 LVAD patients (40 HM3, 19 HVAD). Platelet -selectin expression, activated glycoprotein (GP) IIb/IIIa and monocyte-platelet aggregates (MPA) were assessed by flow-cytometry. Platelet aggregation was measured by light-transmission aggregometry (LTA) and multiple-electrode aggregometry (MEA). Von-Willebrand factor (VWF) antigen (VWF:Ag), VWF activity (VWF:Ac), and VWF multimer pattern analysis were determined. Soluble -selectin (sP-selectin) was measured with an enzyme-linked immunoassay. -selectin, GPIIb/IIIa and MPA levels and in response to arachidonic acid, adenosine diphosphate, and thrombin receptor activating peptide were similar between HM3 and HVAD (all > .05). Likewise, agonist-inducible platelet aggregation by LTA and MEA did not differ between HM3 and HVAD (all > .05). VWF:Ag levels and FVIII:C were similar between both systems (both > .05), but patients with HVAD had significantly lower VWF:Ac ( = .011) and reduced large VWF multimers ( = .013). Finally, sP-selectin levels were similar in patients with HVAD and HM3 ( = .845). In conclusion, on-treatment platelet activation and aggregation are similar in HM3 and HVAD patients. Potential clinical implications of observed differences in VWF profiles between both LVAD systems need to be addressed in future clinical trials.
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http://dx.doi.org/10.1080/09537104.2021.1881950DOI Listing
March 2021

Implanting the HeartMate 6 (total artificial heart).

Multimed Man Cardiothorac Surg 2021 03 2;2021. Epub 2021 Mar 2.

Department of Cardiac Surgery, Medical University of Vienna, Austria

The HeartMate 3 is a ventricular assist device that supports the heart with a centrifugal continuous flow. It contains a fully levitated rotor to minimize hemolysis and was initially designed as an apical intrapericardial implant. It can be used as a bridge to a transplant, to recovery, or to destination therapy. After we excise the ventricles, we implant 2 HeartMate 3 devices as a total artificial heart (HeartMate 6). The patient was 35 years old when the devices were implanted and had been diagnosed with Yamaguchi syndrome (apical hypertrophic cardiomyopathy) at 13 years of age. Being listed for a transplant was not an option due to secondary pulmonary hypertension. Furthermore, the conventional method of apically implanting a left ventricular assist device was not possible due to the underlying pathology. A HeartMate 6 implant as a bridge to transplant therapy was planned. Additionally, a CardioMEMS HF System was implanted to monitor the pulmonary artery pressure. The video tutorial provides step-by-step instructions for implanting 2 HeartMate 3 devices as a total artificial heart.
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http://dx.doi.org/10.1510/mmcts.2021.012DOI Listing
March 2021

Impact of Less Invasive Left Ventricular Assist Device Implantation on Heart Transplant Outcomes.

Semin Thorac Cardiovasc Surg 2021 Feb 17. Epub 2021 Feb 17.

Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Cardiovascular Research, Vienna, Austria. Electronic address:

Left ventricular assist device implantation without sternotomy (LIS) may simplify heart transplantation (HTX) by avoiding adhesions and eliminating the need for a re-sternotomy. This study investigates the impact of LIS LVAD implantation on HTX outcomes. A retrospective comparison of 46 patients undergoing HTX between 07/13 and 06/19 after conventional LVAD implantation with a full sternotomy (FS) and LIS LVAD implantation (LIS: n = 27 patients, 59%; FS: n = 19 patients, 41%) was performed. Endpoints were perioperative data including blood product use, de-novo formation of donor specific antibodies (DSAs) and survival. Patient demographics (mean age FS: 60.3 ± 9.3 years vs LIS 58.0 ± 7.7 years, P = 0.313; male gender FS: 84% vs LIS: 82%, P = 1.000; urgent HTX FS: 16% vs LIS 18%, P = 1.000) were comparable between LIS and FS patients. The primary finding was a significantly higher risk to develop de novo donor specific antibodies (DSAs) after HTX in patients of the FS group (FS: 36% vs LIS: 4%; P = 0.006). LIS patients had a significant reduction of intraoperative packed red blood cells (PRBCs) use (LIS: 4 (IQR 2-7) Units vs FS: 7 (IQR 4-8) Units; P = 0.045). Other adverse events rates and in-hospital mortality (LIS: 7% vs FS 5%, P = 1.000) were comparable between both groups. LIS LVAD reduces formation of donor specific antibodies after HTX.
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http://dx.doi.org/10.1053/j.semtcvs.2021.02.001DOI Listing
February 2021

Nasogastric tube placement in critically ill patients-stay alert!

J Card Surg 2021 Apr 18;36(4):1546-1547. Epub 2021 Feb 18.

Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.

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http://dx.doi.org/10.1111/jocs.15435DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986376PMC
April 2021

Cardio-microcurrent device for chronic heart failure: first-in-human clinical study.

ESC Heart Fail 2021 04 9;8(2):962-970. Epub 2021 Feb 9.

Cardiovascular Institute Dedinje Belgrade, Belgrade, Serbia.

Aims: Most devices for treating ambulatory Class II and III heart failure are linked to electrical pulses. However, a steady electric potential gradient is also necessary for appropriate myocardial performance and may be disturbed by structural heart diseases. We investigated whether chronic application of electrical microcurrent to the heart is feasible and safe and improves cardiac performance. The results of this study should provide guidance for the design of a two-arm, randomized, controlled Phase II trial.

Methods And Results: This single-arm, non-randomized pilot study involved 10 patients (9 men; mean age, 62 ± 12 years) at two sites with 6 month follow-up. All patients had New York Heart Association (NYHA) Class III heart failure and non-ischaemic dilated cardiomyopathy, with left ventricular ejection fraction (LVEF) <35%. A device was surgically placed to deliver a constant microcurrent to the heart. The following tests were performed at baseline, at hospital discharge, and at six time points during follow-up: determination of LVEF and left ventricular end-diastolic/end-systolic diameter by echocardiography; the 6 min walk test; and assessment of NYHA classification and quality of life (36-Item Short-Form Health Survey questionnaire). Microcurrent application was feasible and safe; no device-related or treatment-related adverse events occurred. During follow-up, rapid and significant signal of efficacy (P < 0.005) was present with improvements in LVEF, left ventricular end-diastolic diameter, left ventricular end-systolic diameter, and distance walked. For eight patients, NYHA classification improved from Class III to Class I (for seven, as early as 14 days post-operatively); for one, to Class II; and for one, to Class II/III. 36-Item Short-Form Health Survey questionnaire scores also improved highly significantly.

Conclusions: Chronic application of microcurrent to the heart is feasible and safe and leads to a rapid and lasting improvement in heart function and a near normalization of heart size within days. The NYHA classification and quality of life improve just as rapidly.
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http://dx.doi.org/10.1002/ehf2.13242DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8006737PMC
April 2021

Anterior Right Thoracotomy for Rapid-Deployment Aortic Valve Replacement.

Ann Thorac Surg 2021 08 2;112(2):564-571. Epub 2020 Nov 2.

Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.

Background: Minimally invasive aortic valve replacement through anterior right thoracotomy (ART) has shown to be safe and feasible. However, acceptance within the surgical community is low. Rapid-deployment aortic valves may be a game changer due to simplified surgical technique and shorter operative times. Therefore, the combination of advanced surgical techniques like the ART access with rapid-deployment aortic valves was assessed in this study.

Methods: We retrospectively analyzed all patients undergoing ART with the Edwards Intuity Elite (Edwards Lifesciences, Irvine, CA) valve system between 2011 and 2018. Patient data were collected prospectively in an ongoing, single-center registry. Data analysis regarding valve outcome was performed according to current guidelines.

Results: In all, 165 patients underwent aortic valve replacement through ART access with the Edwards Intuity valve system (age 73 ± 9 years, 49% female, median European System for Cardiac Operative Risk Evaluation II score 1.6 [range, 0.6 to 10.6]). Median cardiopulmonary bypass time was 114 minutes (range, 61 to 310) and median aortic cross-clamp time was 80 minutes (range, 45 to 230). Thirty-day as well as inhospital mortality was 0.6% (n = 1). Postoperative neurologic events occurred in 3%, resulting in major neurologic deficit in 1 patient. Intermediate and long-term survival was 99%, 98%, and 93% after 6 months, 1 year, and 3 years, respectively.

Conclusions: Implantation of the Edwards Intuity valve system through ART is safe, feasible, and reproducible. The overall results of this single center experience are excellent compared with contemporary series of both surgical and transcatheter aortic valve replacements.
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http://dx.doi.org/10.1016/j.athoracsur.2020.09.023DOI Listing
August 2021

Left ventricular assist device driveline infections in three contemporary devices.

Artif Organs 2021 May 28;45(5):464-472. Epub 2020 Nov 28.

Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.

Driveline infections (DLI) are common adverse events in left ventricular assist devices (LVADs), leading to severe complications and readmissions. The study aims to characterize risk factors for DLI readmission 2 years postimplant. This single-center study included 183 LVAD patients (43 HeartMate II [HMII], 29 HeartMate 3 [HM3], 111 HVAD) following hospital discharge between 2013 and 2017. Demographics, clinical parameters, and outcomes were retrospectively analyzed and 12.6% of patients were readmitted for DLI, 14.8% experienced DLI but were treated in the outpatient setting, and 72.7% had no DLI. Mean C-reactive protein (CRP), leukocytes and fibrinogen were higher in patients with DLI readmission (P < .02) than in outpatient DLI and patients without DLI, as early as 60 days before readmission. Freedom from DLI readmission was comparable for HMII and HVAD (98% vs. 87%; HR, 4.52; 95% CI, 0.58-35.02; P = .15) but significantly lower for HM3 (72%; HR, 10.82; 95% CI, 1.26-92.68; P = .03). DLI (HR, 1.001; 95% CI, 0.999-1.002; P = .16) or device type had no effect on mortality. DLI readmission remains a serious problem following LVAD implantation, where CRP, leukocytes, and fibrinogen might serve as risk factors already 60 days before. HM3 patients had a higher risk for DLI readmissions compared to HVAD or HMII, possibly because of device-specific driveline differences.
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http://dx.doi.org/10.1111/aor.13843DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8247301PMC
May 2021

Impact of Subclinical Congestion on Outcome of Patients Undergoing Mitral Valve Surgery.

Biomedicines 2020 Sep 19;8(9). Epub 2020 Sep 19.

Division of Cardiac Surgery, Medical University of Vienna, 1090 Vienna, Austria.

Since risk assessment prior to cardiac surgery is based on proven but partly unsatisfactory scores, the need for novel tools in preoperative risk assessment taking into account cardiac decompensation is obvious. Even subclinical chronic heart failure is accompanied by an increase in plasma volume. This increase is illustrated by means of a plasma volume score (PVS), calculated using weight, gender and hematocrit. A retrospective analysis of 187 consecutive patients with impaired left ventricular function undergoing mitral valve surgery at a single centre between 2013 and 2016 was conducted. Relative preoperative PVS was generated by subtracting the ideal from actual calculated plasma volume. The study population was divided into two cohorts using a relative PVS score > 3.1 as cut-off. Patients with PVS > 3.1 had a significantly higher need for reoperation for bleeding/tamponade (5.5% vs. 16.7%; = 0.016) and other non-cardiac causes (9.4% vs. 21.7%; = 0.022). In-hospital as well as 6-month, 1-year and 5-year mortality was significantly increased in PVS > 3.1 (6.3% vs. 18.3%; = 0.013; 9.4% vs. 23.3%; = 0.011; 11.5% vs. 23.3%; = 0.026; 18.1% vs. 33.3%; = 0.018). Elevated PVS above the defined cut-off used to quantify subclinical congestion was linked to significantly worse outcome after mitral valve surgery and therefore could be a useful addition to current preoperative risk stratification.
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http://dx.doi.org/10.3390/biomedicines8090363DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7555884PMC
September 2020

Thrombolysis as first-line therapy for Medtronic/HeartWare HVAD left ventricular assist device thrombosis.

Eur J Cardiothorac Surg 2020 12;58(6):1182-1191

Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.

Objectives: We reviewed our institutional experience with intravenous thrombolysis (TL) as first-line therapy in patients with Medtronic/HeartWare HVAD left ventricular assist device pump thrombosis (PT).

Methods: From March 2006 to November 2018, 30 Medtronic/HeartWare HVAD left ventricular assist device patients had 48 PT events. We analysed outcomes with intravenous Alteplase as a first-line therapy for PT. Pump exchange or urgent heart transplantation was only considered after the failure of TL or existing contraindications to TL.

Results: TL was used as the first-line therapy in 44 PT events in 28 patients without a contraindication to TL. TL was successful in 61.4% of PT events. More than 1 cycle of TL was necessary in 55.6% of events. The combined success of TL and heart transplantation or device exchange was 81.8%. In 15.9% of events, PT was fatal. Causes of death were severe complications (9.1%) related to TL or discontinuation of therapy for multi-organ failure (6.8%). Intracranial bleeding and arterial thromboembolism were observed in 4.5% and 11.5% of the PT events after TL.

Conclusions: Intravenous TL as a first-line therapy for PT in Medtronic/HeartWare HVAD patients can be a reasonable treatment option and does not preclude subsequent heart transplantation or device exchange. However, thromboembolic and bleeding complications are common. The decision to perform TL or device exchange should, therefore, be made on an individual basis after balancing the risks and benefits of different treatment approaches.
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http://dx.doi.org/10.1093/ejcts/ezaa180DOI Listing
December 2020

[Recommendations for Extracorporeal Membrane Oxygenation (ECMO) in COVID-19 Patients].

Wien Klin Mag 2020 Jun 10:1-6. Epub 2020 Jun 10.

Universitätsklinik für Innere Medizin I, Allgemeines Krankenhaus der Stadt Wien, Medizinische Universität Wien, Währinger Gürtel 18-20, 1090 Wien, Österreich.

The pandemic from the SARS-CoV‑2 Virus is currently challenging health care systems all over the world. Maintaining appropriate staffing and resources in healthcare facilities is essential to guarantee a safe work environment for healthcare personnel and safe patient care. Extracorporeal membrane oxygenation (ECMO) represents a valuable therapeutic option in patients with severe heart or lung failure. Although only a limited proportion of COVID-19 patients develops respiratory or circulatory failure that is refractory to conventional therapies, it is of utmost importance to clearly define criteria for the use of ECMOs in this steadily growing patient population. The ECMO working group of the Medical University of Vienna has established the following recommendations for ECMO support in COVID-19 patients.
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http://dx.doi.org/10.1007/s00740-020-00349-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7286215PMC
June 2020

Decrease in serum alkaline phosphatase and prognostic relevance in adult cardiopulmonary bypass.

Interact Cardiovasc Thorac Surg 2020 09;31(3):383-390

Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.

Objectives: Cardiopulmonary bypass (CPB) induces inflammatory responses, which may lead to the loss of alkaline phosphatase (AP) that is consumed in the process of dephosphorylating detrimental extracellular nucleotides in this proinflammatory state. It has been reported that low postoperative AP levels correlate with increased postoperative support requirement and organ dysfunction after paediatric cardiac surgery. However, little is known about the perioperative development and clinical relevance of AP depletion in adults undergoing CPB.

Methods: A total of 183 patients with a preoperative left ventricular ejection fraction ≤50% undergoing mitral valve surgery ± concomitant related procedures at the Department of Cardiac Surgery, Medical University of Vienna, between 2013 and 2016 were included in this retrospective analysis. Serum AP measurements at baseline and on postoperative days 1-15 were collected. Absolute and relative drop of AP on postoperative day 1 from baseline was correlated with perioperative and early postoperative parameters. Receiver operating characteristics were used to define suitable predictors and cut-offs for postoperative outcome variables.

Results: Receiver operating characteristics showed a reduction of >50% of baseline AP to predict in-hospital mortality [area under the curve (AUC) 0.807], prolonged intensive care unit stay (>72 h, AUC 0.707), prolonged mechanical ventilation (>24 h, AUC 0.712) and surgery-related dialysis requirement (AUC 0.736). Patients with a perioperative reduction in circulating AP to levels below 50% of baseline had a significantly decreased survival. Patients with high perioperative AP loss had higher preoperative AP levels (P < 0.001), longer CPB duration (P < 0.001) and higher incidence of extracorporeal membrane oxygenation support (P < 0.001).

Conclusions: Increased perioperative AP loss is associated with adverse early outcome. Prospective trials are needed to determine whether this effect can be counteracted by perioperative AP supplementation.
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http://dx.doi.org/10.1093/icvts/ivaa103DOI Listing
September 2020

Interdependence of VA-ECMO output, pulmonary congestion and outcome after cardiac surgery.

Eur J Intern Med 2020 11 28;81:67-70. Epub 2020 Jul 28.

Department of Internal Medicine II, Medical University of Vienna, Austria.

Background: Venoarterial-extracorporeal membrane oxygenation (VA-ECMO) is a life-saving method for patients with low-output failure after cardiac surgery. However, VA-ECMO therapy may increase left ventricular afterload due to retrograde blood flow in the aorta, which may lead to progression of pulmonary congestion. We examined the predictive value of pulmonary congestion in patients that need VA-ECMO support after cardiovascular surgery.

Methods: We enrolled a total of 266 adult patients undergoing VA-ECMO support following cardiovascular surgery at a university-affiliated tertiary care centre into our single-center registry. Pulmonary edema was assessed on bedside chest X rays at day 0, 3, 5 after VA-ECMO implantation.

Results: Median age was 65 (57-72) years, 69% of patients were male and 30-day survival was 63%. At ICU-admission 20% of patients had mild, 54% had moderate and 26% showed severe pulmonary congestion. Pulmonary congestion at day 0 was not associated with outcome (adjusted HR 1.31; 95%-CI 0.89-1.93;P = 0.18), whereas pulmonary congestion at day 3 (adj. HR 2.81; 95%-CI 1.76-4.46;P<0.001) and day 5 (adj. HR 3.01;95%-CI 1.84-4.93;P<0.001) was significantly associated with survival. Linear regression revealed that out of left ventricular function, cardiac output, central venous saturation, maximum dobutamine and norepinephrine dose as well as fluid balance solely ECMO rotation was associated with the evolution of pulmonary congestion (P = 0.007).

Conclusions: Pulmonary edema three and five days after ECMO implantation are associated with poor survival. Interestingly, a high VA-ECMO output was the most important determinant of worsening pulmonary congestion within the first five days.
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http://dx.doi.org/10.1016/j.ejim.2020.07.014DOI Listing
November 2020

Acute oxygenator occlusion in two cases of polycythemia vera: Bailout strategies.

J Card Surg 2020 Oct 15;35(10):2835-2837. Epub 2020 Jul 15.

Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria.

Polycytemia vera (PV) is a rare myeloproliferative neoplasm associated with microcirculatory disturbances, thrombosis and bleeding. Patients suffering from PV have a high risk of perioperative adverse events, but the literature regarding on-pump procedures in PV patients is scarce. We report two cases of acute and severe oxygenator failure during cardiopulmonary bypass and present valid exit scenarios.
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http://dx.doi.org/10.1111/jocs.14876DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7586822PMC
October 2020

Recommendations for extracorporeal membrane oxygenation (ECMO) in COVID-19 patients : Consensus paper of the Medical University of Vienna.

Wien Klin Wochenschr 2020 Nov 3;132(21-22):671-676. Epub 2020 Jul 3.

University Department of Medicine I, Vienna General Hospital, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.

The pandemic from the SARS-CoV‑2 virus is currently challenging healthcare systems all over the world. Maintaining appropriate staffing and resources in healthcare facilities is essential to guarantee a safe working environment for healthcare personnel and safe patient care. Extracorporeal membrane oxygenation (ECMO) represents a valuable therapeutic option in patients with severe heart or lung failure. Although only a limited proportion of COVID-19 patients develop respiratory or circulatory failure that is refractory to conventional treatment, it is of utmost importance to clearly define criteria for the use of ECMO in this steadily growing patient population. The ECMO working group of the Medical University of Vienna has established the following recommendations for ECMO support in COVID-19 patients.
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http://dx.doi.org/10.1007/s00508-020-01708-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7332739PMC
November 2020

Blood stream infection and outcomes in recipients of a left ventricular assist device.

Eur J Cardiothorac Surg 2020 11;58(5):907-914

Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.

Objectives: Our aim was to investigate associations between blood stream infection [≥1 positive blood culture (BC)] and outcomes in recipients of a left ventricular assist device (LVAD).

Methods: We retrospectively analysed all adult recipients of a continuous-flow LVAD between 2006 and 2016 at the Division of Cardiac Surgery, Medical University of Vienna (n = 257; devices: Medtronic HeartWare® HVAD®, Abbott HeartMate II®, Abbott HeartMate 3™). The primary outcome was all-cause mortality during follow-up. Secondary outcomes included the risk of stroke and pump thrombus during follow-up as well as the probability of heart transplantation (HTx). Risk factors for the development of ≥1 positive BC were evaluated additionally.

Results: The incidence of ≥1 positive BC during the first year of LVAD support was 32.1% [95% confidence interval (CI) 26.4-37.9]. Multivariable Cox proportional cause-specific hazards regression analysis showed that a positive BC was associated with significantly increased all-cause mortality [hazard ratio (HR) 5.51, 95% CI 3.57-8.51; P < 0.001]. Moreover, a positive BC was associated with a significantly increased risk of stroke (HR 2.41, 95% CI 1.24-4.68; P = 0.010). There was no association with the risk of pump thrombus or the probability of HTx. Independent risk factors for a positive BC included preoperative albumin and extracorporeal membrane oxygenation/intra-aortic balloon pump support.

Conclusions: Blood stream infection is common and associated with a significantly increased risk of all-cause mortality and stroke at any given time during LVAD support. Effective strategies of prevention and treatment are necessary.
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http://dx.doi.org/10.1093/ejcts/ezaa153DOI Listing
November 2020

International Normalized Ratio Test Frequency in Left Ventricular Assist Device Patients Affects Anticoagulation Quality and Adverse Events.

ASAIO J 2021 02;67(2):157-162

From the Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Austria.

Anticoagulation therapy in patients using left ventricular assist device (LVAD) is essential to reduce hemocompatibility related adverse events (HRAEs). Vitamin K-antagonist dosage must be adapted and monitored by INR point-of-care testing (POCT) in outpatients. The study aims to determine if the frequency of INR POCT in LVAD outpatients has an influence on the quality of anticoagulation therapy (ACQ), HRAEs, and outcomes. This retrospective study included n = 48 patients who received LVAD implantation (HMII, HM3, and HVAD) between 2013 and 2017. ACQ (% of INR tests in range, PTR), outcomes and HRAEs using Kaplan-Meier curves were compared in a daily (n = 36) and 3×/week (n = 12) INR POCT group. Further, based on the achieved PTR ranging from 0-60% (poor), 61-70% (acceptable), and 71-100% (well controlled), HRAEs and outcomes were compared. Daily and 3×/week groups were similar in perioperative risk factors and INR target (p = 0.28). Freedom from any HRAE (38.9% vs. 25.0%, p = 0.44), any readmission (72.2% vs. 75.0%, p = 0.97), and 1 year survival (91.7% vs. 91.7%, p = 0.98) were comparable in both groups. The PTR was significantly higher with the daily self-assessments (73.5% vs. 68.4%, p = 0.006). Well vs. poorly controlled INR POCT patients more often had (p = 0.01) a daily POCT frequency (92%) vs. poorly controlled (54%) and significantly higher freedom from neurologic events (96.0 vs. 69.2%, p = 0.024) as well as hemorrhagic strokes (100% vs. 76.9%, p = 0.011). Well-controlled anticoagulation of LVAD outpatients is associated with less neurologic events. The frequency of INR POCT could be one of the key factors in the reduction of HRAEs, so future prospective, large-scale studies should help to clarify the effects.
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http://dx.doi.org/10.1097/MAT.0000000000001206DOI Listing
February 2021

Less Invasive Left Ventricular Assist Device Implantation Is Safe and Reduces Intraoperative Blood Product Use: A Propensity Score Analysis VAD Implantation Techniques and Blood Product Use.

ASAIO J 2021 01;67(1):47-52

From the Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria.

Despite increasing popularity and multiple postulated benefits, less invasive (LIS) left ventricular assist device (LVAD) implantation has not been sufficiently compared with standard full sternotomy (FS). We report the outcomes of a propensity score analysis designed to compare LIS and FS LVAD implantation, with perioperative blood product use, adverse event rates, and mortality as primary objective. From September 2010 to August 2016, 159 consecutive patients received a Medtronic HVAD or Abbott HeartMate 3 LVAD via a FS or LIS approach. Outcomes were analyzed using proportional hazard Cox regression, with risk adjustment based on a LIS approach propensity score model computed from demographics, risk factors, and operative covariates. Seventy-five patients were matched and compared (HVAD 83% [n = 62]; LIS approach 43% [n = 32]; mean age 60 ± 12 years; 89% [n = 67] male; 48% [n = 36] ischemic cardiomyopathy [ICMP]; 37% [n = 28]). Patient groups were comparable with regard to preoperative patient characteristics. Less invasive LVAD implantation was successful in all patients with no intraoperative conversions. In-hospital mortality was 16% in both groups, despite 37% Interagency Registry for Mechanically Assisted Circulatory Support Level I patients. Overall, 28% of the LIS patients did not receive any blood products intraoperatively, whereas, in the FS group, only two patients (5%) did not require the administration of blood products (p = 0.000). This was also a significant finding in the overall perioperative phase in which seven LIS patients (22%) who not receive any blood products versus two FS patients (5%; p = 0.033). Otherwise, outcomes were comparable. Less invasive LVAD implantation is a feasible, safe, and reduces blood product use.
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http://dx.doi.org/10.1097/MAT.0000000000001165DOI Listing
January 2021

Hemodynamic exercise responses with a continuous-flow left ventricular assist device: Comparison of patients' response and cardiorespiratory simulations.

PLoS One 2020 18;15(3):e0229688. Epub 2020 Mar 18.

Center for Medical Physics and Biomedical Engineering, Medical University of Vienna, Vienna, Austria.

Background: Left ventricular assist devices (LVADs) are an established treatment for end stage heart failure patients. As LVADs do not currently respond to exercise demands, attention is also directed towards improvements in exercise capacity and resulting quality of life. The aim of this study was to explore hemodynamic responses observed during maximal exercise tests to infer underlying patient status and therefore investigate possible diagnostics from LVAD derived data and advance the development of physiologically adaptive LVAD controllers.

Methods: High resolution continuous LVAD flow waveforms were recorded from 14 LVAD patients and evaluated at rest and during maximum bicycle exercise tests (n = 24). Responses to exercise were analyzed in terms of an increase (↑) or decrease (↓) in minimum (QMIN), mean (QMEAN), maximum flow (QMAX) and flow pulsatility (QP2P). To interpret clinical data, a cardiorespiratory numerical simulator was used that reproduced patients' hemodynamics at rest and exercise. Different cardiovascular scenarios including chronotropic and inotropic responses, peripheral vasodilation, and aortic valve pathologies were simulated systematically and compared to the patients' responses.

Results: Different patients' responses to exercise were observed. The most common response was a positive change of ΔQMIN↑ and ΔQP2P↑ from rest to exercise (70% of exercise tests). Two responses, which were never reported in patients so far, were distinguished by QMIN↑ and QP2P↓ (observed in 17%) and by QMIN↓ and QP2P↑ (observed in 13%). The simulations indicated that the QP2P↓ can result from a reduced left ventricular contractility and that the QMIN↓ can occur with a better left ventricular contractility and/or aortic insufficiency.

Conclusion: LVAD flow waveforms determine a patients' hemodynamic "fingerprint" from rest to exercise. Different waveform responses to exercise, including previously unobserved ones, were reported. The simulations indicated the left ventricular contractility as a major determinant for the different responses, thus improving patient stratification to identify how patient groups would benefit from exercise-responsive LVAD control.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0229688PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7080259PMC
June 2020

Transcatheter edge-to-edge tricuspid repair for recurrence of valvular regurgitation after left ventricular assist device and tricuspid ring implantation.

ESC Heart Fail 2020 06 7;7(3):915-919. Epub 2020 Mar 7.

Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, 1090, Austria.

Tricuspid regurgitation in patients with left ventricular assist device (LVAD) has a significant impact on prognosis and quality of life, and its effects on liver and renal function could negatively impact planned heart transplantation. The aim of the present case is to report the feasibility and the clinical impact of tricuspid transcatheter edge-to-edge repair in LVAD patients as adjunctive bridge to transplantation strategy. A 59-year-old female patient previously treated with LVAD implantation (HeartMate III) and tricuspid valve repair with 32 mm rigid ring (Medtronic Contour 3D) as bridge to transplantation developed recurrence of significant tricuspid regurgitation with right ventricular decompensation needing inotropic support. Preoperative echo showed torrential tricuspid valve regurgitation Effective regurgitant orifice area(EROA 1.4 cm ) with suspicious of partial detachment of the prosthetic ring. The patient was successfully treated with transcatheter edge-to-edge repair with the MitraClip XTR device. Tricuspid regurgitation was reduced by 50% (postoperative EROA 0.7 cm ). She remained stable under continuous inotropic support with no other episodes of right ventricular decompensation and was successfully transplanted 30 days after the clipping procedure. Transcatheter treatment of tricuspid regurgitation in a patient with LVAD was an effective strategy to gain time and bridge the patient to heart transplantation.
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http://dx.doi.org/10.1002/ehf2.12577DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261524PMC
June 2020

Isolated tricuspid valve regurgitation: old concepts, new insights and innovation.

J Cardiovasc Med (Hagerstown) 2020 Jun;21(6):406-414

Department of Cardiac Surgery.

: Tricuspid valve regurgitation is usually progressive and associated with reduced long-term survival. International guidelines recommend surgery in cases of isolated severe regurgitation associated with symptoms or progressive worsening of right ventricular function. In addition, several percutaneous strategies have been reported with promising results in the last decade. The aim of the present review is to summarize the current state of the art in the management of isolated functional or degenerative tricuspid valve insufficiency, from the preoperative assessment to the results of both surgical and transcatheter approaches and explore future directions.
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http://dx.doi.org/10.2459/JCM.0000000000000933DOI Listing
June 2020

Extra-anatomic aortic bypass with aortic-, mitral-, and tricuspid surgery in a 53-year old: A single-stage approach for complex coarctation associated with triple valve pathology.

J Card Surg 2020 Apr 17;35(4):937-939. Epub 2020 Feb 17.

Division of Cardiac Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria.

Coarctation is rare in patients over 50 years of age; however, if present, it can be associated with complex intracardiac pathologies and represent a formidable surgical challenge. Herein, we report a single-stage approach for surgical repair of coarctation associated with aortic, mitral, and tricuspid valve pathology using an ascending-to-descending aortic bypass with posterior pericardial access.
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http://dx.doi.org/10.1111/jocs.14465DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7187478PMC
April 2020
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