Publications by authors named "Sven Martens"

93 Publications

Impact of cardiac fibrosis and collagens on right ventricular failure and acute kidney injury in patients after continuous-flow left ventricular assist devices.

Interact Cardiovasc Thorac Surg 2021 Jul 12. Epub 2021 Jul 12.

Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany.

Objectives: We aim to investigate the impact of cardiac fibrosis and collagens on right ventricular failure (RVF) and acute kidney injury (AKI) in patients receiving continuous flow left ventricular assist devices.

Methods: Heart tissues from 34 patients were obtained from continuous flow left ventricular assist device insertion sites and corresponding clinical data were collected. The participants were divided into 2 groups according to the extent of the cardiac fibrosis or collagens.

Results: Overall, 18 patients developed RVF with 14 receiving right ventricular assist device (RVAD), and 22 patients developed AKI with 12 needing new-onset renal replacement therapy. Higher collagen I (Col1) was significantly associated with increased incidences of RVF (76.5% vs 29.4%, P = 0.015), RVAD support (64.7% vs 17.6%, P = 0.013) and stage 3 AKI (58.8% vs 17.6%, P = 0.032), and patients with higher Col1 were more prone to renal replacement therapy (52.9% vs 17.6%, P = 0.071). Receiver operating characteristic curves showed that Col1 had good predictive effects on RVF [area under the curve (AUC) = 0.806, P = 0.002], RVAD support (AUC = 0.789, P = 0.005), stage 3 AKI (AUC = 0.740, P = 0.020) and renal replacement therapy (AUC = 0.731, P = 0.028) after continuous-flow left ventricular assist device. Moreover, patients with higher Col1 had significantly longer postoperative duration of mechanical ventilation, duration of intensive care unit stay and hospital length of stay (all P < 0.05). Cardiac fibrosis, collagen III (Col3) and Col1/Col3 shared similar results or trends with Col1.

Conclusions: Cardiac fibrosis and related collagens in the apical left ventricular tissue are associated with increased risks of RVF, RVAD use and worse renal function. Further study is warranted owing to the small sample size.
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http://dx.doi.org/10.1093/icvts/ivab180DOI Listing
July 2021

Central and peripheral arterial diseases in chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference.

Kidney Int 2021 07 5;100(1):35-48. Epub 2021 May 5.

Department of Cardiology I: Coronary and Peripheral Vascular Disease, Heart Failure, University Hospital Münster, Münster, Germany. Electronic address:

Chronic kidney disease (CKD) affects about 10% of all populations worldwide, with about 2 million people requiring dialysis. Although patients with CKD are at high risk of cardiovascular disease and events, they are often underrepresented or excluded in clinical trials, leading to important knowledge gaps about how to treat these patients. KDIGO (Kidney Disease: Improving Global Outcomes) convened the fourth clinical Controversies Conference on the heart, kidney and vasculature in Dublin, Ireland, in February 2020, entitled Central and Peripheral Arterial Diseases in Chronic Kidney Disease. A global panel of multidisciplinary experts from the fields of nephrology, cardiology, neurology, surgery, radiology, vascular biology, epidemiology, and health economics attended. The objective was to identify key issues related to the optimal detection, management, and treatment of cerebrovascular diseases, central aortic disease, renovascular disease, and peripheral artery disease in the setting of CKD. This report outlines the common pathophysiology of these vascular processes in the setting of CKD, describes best practices for their diagnosis and management, summarizes areas of uncertainty, addresses ongoing controversial issues, and proposes a research agenda to address key gaps in knowledge that, when addressed, could improve patient care and outcomes.
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http://dx.doi.org/10.1016/j.kint.2021.04.029DOI Listing
July 2021

Quantification of volume changes in the descending aorta after frozen elephant trunk procedure using the Thoraflex hybrid prosthesis for type A aortic dissection.

J Thorac Dis 2021 Jan;13(1):60-66

Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University Hospital Muenster, Muenster, Germany.

Background: Frozen elephant trunk (FET) is an established approach to reduce late complications of type A aortic dissection (AADA) by diminishing false lumen perfusion. Currently, surface size of aortic lumina are evaluated using Computed tomography (CT). However, this 2D method is prone to error as it evaluates dissection progression slice by slice. Volume measurement on the other hand can overcome this limitation and deliver better insights in aortic remodeling. Therefore, the aim was to quantify volume changes of the descending and abdominal aorta at short- and mid-term follow-up after FET.

Methods: Between April 2015 and March 2018, 20 patients who underwent surgical repair of AADA using the Thoraflex™ Hybrid Plexus (Vascutek, Terumo Aortic, Scotland) were included in this study. We measured volumetric change before surgical treatment, at discharge, at 12 and at 24 months based on CTAs (Computed tomography angiography). Surfaces and volumes have been analyzed using Aquarius iNtuition (TeraRecon Inc., Foster City, CA, USA).

Results: One hundred fifty-eight volumetric measures were obtained. The findings show a significant increase of volume of the true lumen (TL) while surface measurement of the TL did not show any significant change at other levels besides level C (diaphragm, P=0.00193). Variance analysis showed significant increase of volume, whereas no significant change was seen in false lumen. Post-hoc analysis revealed a significance at 24 months (P=0.047).

Conclusions: Although previous studies outline the clinical benefit of Thoraflex hybrid prosthesis on short-term follow up, this study provides a more precise understanding of aortic remodeling based on volumetric measurement. Thus, quantification of volume changes should be included for the assessment of optimal follow-up timing and consecutive procedure planning.
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http://dx.doi.org/10.21037/jtd-20-2356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7867847PMC
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

Effects of Different Doses of Remote Ischemic Preconditioning on Kidney Damage Among Patients Undergoing Cardiac Surgery: A Single-Center Mechanistic Randomized Controlled Trial.

Crit Care Med 2020 08;48(8):e690-e697

Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany.

Objectives: We have previously shown that remote ischemic preconditioning reduces acute kidney injury (acute kidney injury) in high-risk patients undergoing cardiopulmonary bypass and that the protective effect is confined to patients who exhibit an increased urinary tissue inhibitor of metalloproteinases-2 and insulin-like growth factor-binding protein 7 in response to remote ischemic preconditioning. The purpose of this study was to determine the optimal intensity of remote ischemic preconditioning to induce required [tissue inhibitor of metalloproteinases-2]*[insulin-like growth factor-binding protein 7] changes and further explore mechanisms of remote ischemic preconditioning.

Design: Observational and randomized controlled, double-blind clinical trial.

Setting: University Hospital of Muenster, Germany.

Patients: High-risk patients undergoing cardiac surgery as defined by the Cleveland Clinic Foundation Score.

Interventions: In the interventional part, patients were randomized to receive either one of four different remote ischemic preconditioning doses (3 × 5 min, 3 × 7 min, 3 × 10 min remote ischemic preconditioning, or 3 × 5 min remote ischemic preconditioning + 2 × 10 min remote ischemic preconditioning in nonresponders) or sham-remote ischemic preconditioning (control).

Measurements And Main Results: The primary endpoint of the interventional part was change in urinary [tissue inhibitor of metalloproteinases-2]*[insulin-like growth factor-binding protein 7] between pre- and postintervention. To examine secondary objectives including acute kidney injury incidence, we included an observational cohort. A total of 180 patients were included in the trial (n = 80 observational and n = 100 randomized controlled part [20 patients/group]). The mean age was 69.3 years (10.5 yr), 119 were men (66.1%). Absolute changes in [tissue inhibitor of metalloproteinases-2]*[insulin-like growth factor-binding protein 7] were significantly higher in all remote ischemic preconditioning groups when compared with controls (p < 0.01). Although we did not observe a dose-response relationship on absolute changes in [tissue inhibitor of metalloproteinases-2]*[insulin-like growth factor-binding protein 7] across the four different remote ischemic preconditioning groups, in the 15 patients failing to respond to the lowest dose, nine (60%) responded to a subsequent treatment at a higher intensity. Compared with controls, fewer patients receiving remote ischemic preconditioning developed acute kidney injury within 72 hours after surgery as defined by both Kidney Disease: Improving Global Outcomes criteria (30/80 [37.5%] vs 61/100 [61.0%]; p = 0.003).

Conclusions: All doses of remote ischemic preconditioning significantly increased [tissue inhibitor of metalloproteinases-2]*[insulin-like growth factor-binding protein 7] and significantly decreased acute kidney injury compared with controls. High-dose remote ischemic preconditioning could stimulate [tissue inhibitor of metalloproteinases-2]*[insulin-like growth factor-binding protein 7] increases in patients refractory to low-dose remote ischemic preconditioning.
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http://dx.doi.org/10.1097/CCM.0000000000004415DOI Listing
August 2020

Acute kidney injury following coronary artery bypass grafting and control angiography: a comprehensive analysis of 221 patients.

Heart Vessels 2021 Jan 11;36(1):1-6. Epub 2020 Jul 11.

Department of Cardiothoracic Surgery, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, 48149, Münster, Germany.

Postoperative coronary angiography offers the basis for prompt management of ischemic complications after coronary artery bypass grafting (CABG). Little is known about the effects of postoperative angiography on renal function. The current study aims to assess the incidence and risk factors for acute kidney injury (AKI) following postoperative coronary angiography. A total of 221 CABG patients (mean age, 67 ± 8 years) underwent postoperative coronary angiography due to perioperative myocardial infarction (PMI). AKI was defined according to the KDIGO criteria. Logistic regression analyses were performed to find out risk factors responsible for AKI and to ascertain significant associations between AKI and in-hospital death. Mean delay from CABG operation to postoperative angiography was 1.4 ± 1.0 days. AKI occurred in 79/221 (36%) patients. Mean serum-creatinine (sCr) values peaked on the first day after the angiography and reached the lowest level at the fourth day. In the multivariable analysis, the following variables were independent predictors for AKI: postoperative peak values of CK-MB (p = 0.049, OR 1.03, 95% CI 1.00-1.06 per 10 U/l), EuroSCORE I (p = 0.011, OR 1.18, 95% CI 1.04-1.35), and AKI before re-angiography (p = 0.004, OR 3.50, 95% CI 1.51-8.16), whereas a delayed angiography (p = 0.031, OR 0.69, 95% CI 0.49-0.97) was protective against AKI. Patients with post-angiography AKI had a significantly higher mortality after multivariable adjustment than patients without AKI (15.5% vs. 2.11%, p = 0.001, OR 5.42, 95% CI 1.35-21.75). Over one-third of patients who undergo postoperatively angiography develop AKI. The occurrence of AKI must be considered during the decision-making prior to coronary angiography, especially in patients presenting the identified risk factors for AKI.
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http://dx.doi.org/10.1007/s00380-020-01655-4DOI Listing
January 2021

Introduction of a CMR-conditional cardiac phantom simulating cardiac anatomy and function and enabling training of interventional CMR procedures.

Sci Rep 2019 12 27;9(1):19852. Epub 2019 Dec 27.

Department of Cardiology, Division of Cardiovascular Imaging, University Hospital Münster, Münster, Germany.

Interventional magnetic resonance imaging (MRI) procedures promise to open-up new vistas regarding clinically relevant diagnostic and/or therapeutic procedures in the field of cardiology. However, a number of major limitations and challenges regarding interventional cardiovascular magnetic resonance (CMR) procedures still delay their translation from pre-clinical studies to human application. A CMR-conditional cardiac phantom was constructed using MR-safe or -conditional materials only that is based on a unique modular composition allowing quick replacement of individual components. A maximal flow of 76 ml/sec in the aorta and 111 ml/sec in the pulmonary artery were measured, whereas the maximal flow velocity was 56 cm/sec and 89 cm/sec, respectively. A conventional wedge-pressure catheter was advanced over a MRI-conditional guidewire into the right ventricle and thereafter positioned in the pulmonary artery. Pulmonary artery pressure was measured, obtaining the following values for our cardiac phantom: max/min/mean = 16/10/12 mmHg. The presented CMR-conditional cardiac phantom is the first of its kind that does not only mimic cardiac mechanics with adjustable fluid pressure in a four chamber setup that is closely adapted to that of the human heart, but also enables introduction and testing of interventional tools such as guidewires and catheters.
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http://dx.doi.org/10.1038/s41598-019-56506-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6934499PMC
December 2019

Aortic valve replacement in a patient with extra-anatomic aortic and subclavian bypasses.

Angiol Sosud Khir 2019 ;25(3):157-162

Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany.

The patient was 62-year-old male who successfully underwent an anatomic repair of aortic coarctation at the age of 15 and an extra-anatomic ascending aorta- to-descending aorta bypass (graft size 20 mm) and an extra-anatomic ascending aorta to the left subclavian artery bypass (graft size 10 mm) at the age of 49. As he grew older he started presenting clinical symptoms of aortic stenosis. The echocardiogram showed a bicuspid aortic valve with severe stenosis and a mean gradient of 65 mm Hg. Despite the high surgical risk, we decided to perform an open valve replacement with installing the CPB prior to re-sternotomy with a simultaneous cannulation of the axillary and femoral arteries by reason of interrupted descending aorta. The postoperative course was uneventful.
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http://dx.doi.org/10.33529/ANGID2019309DOI Listing
November 2019

Elastica degeneration and intimal hyperplasia lead to Contegra® conduit failure.

Eur J Cardiothorac Surg 2019 Dec;56(6):1154-1161

Department of Cardiothoracic Surgery, University Hospital Muenster, Muenster, Germany.

Objectives: Currently, Contegra® grafts (processed bovine jugular vein conduits) are widely used for reconstructive surgery of the right ventricular outflow tract in patients with congenital heart disease (CHD). We analysed explanted Contegra conduits from 2 institutions histologically to get a possible hint at the underlying pathomechanisms of degenerative alterations and to find histological correlations of graft failure. Additionally, we compared the explants with a non-implanted processed graft and a native jugular vein obtained from a young bull.

Methods: The explanted Contegra grafts were gathered during reoperations of 13 patients (male: n = 9, 69.2%; female: n = 4, 30.8%). After standardized histological preparation, samples were stained with dyes haematoxylin and eosin and Elastica van Gieson. Additionally, X-ray pictures revealed the extent of calcification and chelaplex (III)-descaling agent was used to decalcify selected explants.

Results: Processing of the native jugular vein leads to tissue loosening and a loss of elastic fibres. For graft failure after implantation, 2 pathomechanisms were identified: original graft alteration as well as intimal hyperplasia. Elastica degeneration and rearrangement with interfibrillary matrix structures were the main developments observed within the graft itself. Intimal hyperplasia was characterized by fibrous tissue apposition, calcification and heterotopic ossification.

Conclusions: Regression of the elastic fibre network leads to rigidification of the conduit. In Contegra grafts, atherosclerosis-like changes can be considered the leading cause of graft stenosis and insufficiency. We conclude that both observed mechanisms lead to early reoperation in CHD patients.
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http://dx.doi.org/10.1093/ejcts/ezz199DOI Listing
December 2019

Signaling mechanisms inducing hyporesponsiveness of phagocytes during systemic inflammation.

Blood 2019 07 10;134(2):134-146. Epub 2019 May 10.

Institute of Immunology, University of Muenster, Muenster, Germany.

The inflammatory responsiveness of phagocytes to exogenous and endogenous stimuli is tightly regulated. This regulation plays an important role in systemic inflammatory response syndromes (SIRSs). In SIRSs, phagocytes initially develop a hyperinflammatory response, followed by a secondary state of hyporesponsiveness, a so-called "tolerance." This hyporesponsiveness can be induced by endotoxin stimulation of Toll-like receptor 4 (TLR4), resulting in an ameliorated response after subsequent restimulation. This modification of inflammatory response patterns has been described as innate immune memory. Interestingly, tolerance can also be triggered by endogenous TLR4 ligands, such as the alarmins myeloid-related protein 8 (MRP8, S100A8) and MRP14 (S100A9), under sterile conditions. However, signaling pathways that trigger hyporesponsiveness of phagocytes in clinically relevant diseases are only barely understood. Through our work, we have now identified 2 main signaling cascades that are activated during MRP-induced tolerance of phagocytes. We demonstrate that the phosphatidylinositol 3-kinase/AKT/GSK-3β pathway interferes with NF-κB-driven gene expression and that inhibition of GSK-3β mimics tolerance in vivo. Moreover, we identified interleukin-10-triggered activation of transcription factors STAT3 and BCL-3 as master regulators of MRP-induced tolerance. Accordingly, patients with dominant-negative STAT3 mutations show no tolerance development. In a clinically relevant condition of systemic sterile stress, cardiopulmonary bypass surgery, we confirmed the initial induction of MRP expression and the tolerance induction of monocytes associated with nuclear translocation of STAT3 and BCL-3 as relevant mechanisms. Our data indicate that the use of pharmacological JAK-STAT inhibitors may be promising targets for future therapeutic approaches to prevent complications associated with secondary hyporesponsiveness during SIRS.
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http://dx.doi.org/10.1182/blood.2019000320DOI Listing
July 2019

Early Clinical Outcomes of Surgical Myocardial Revascularization for Acute Coronary Syndromes Complicated by Cardiogenic Shock: A Report From the North-Rhine-Westphalia Surgical Myocardial Infarction Registry.

J Am Heart Assoc 2019 05;8(10):e012049

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

Background Coronary artery bypass grafting for acute coronary syndrome complicated by cardiogenic shock ( CS ) is associated with a high mortality. This registry study aimed to distinguish between early surgical outcomes of CS patients with non- ST -segment-elevation myocardial infarction ( NSTEMI ) and ST -segment-elevation myocardial infarction ( STEMI ). Methods and Results Patients with NSTEMI (n=1218) or STEMI (n=618) referred for coronary artery bypass grafting were enrolled in a prospective multicenter registry between 2010 and 2017. CS was present in 227 NSTEMI (18.6%) and 243 STEMI patients (39.3%). Key clinical end points were in-hospital mortality ( IHM ) and major adverse cardiocerebral events ( MACCEs ). Predictors for IHM and MACCEs were identified using multivariable logistic regression analysis. STEMI patients with CS were younger, had a lower prevalence of diabetes mellitus and multivessel disease, and exhibited higher myocardial injury (troponin 9±17 versus 3±6 ng/mL) before surgery compared with patients with NSTEMI ( P<0.05). Emergency coronary artery bypass grafting was performed more often in STEMI (58%) versus NSTEMI (40%; P=0.002). On-pump surgery with cardioplegia was the preferred surgical technique in CS . IHM and MACCE rates were 24% and 49% in STEMI patients with CS and were higher compared with NSTEMI ( IHM 15% versus MACCE 34%; P<0.001). Predictors for IHM and MACCE in CS were a reduced ejection fraction and a higher European System for Cardiac Operative Risk Evaluation score. Conclusions Surgical revascularization in NSTEMI and STEMI patients with CS is associated with a substantial but not prohibitive IHM and MACCE rate. Worse early outcomes were found for patients with STEMI complicated by CS compared with NSTEMI patients.
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http://dx.doi.org/10.1161/JAHA.119.012049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6585325PMC
May 2019

The Transcription Factor ATF4 Promotes Expression of Cell Stress Genes and Cardiomyocyte Death in a Cellular Model of Atrial Fibrillation.

Biomed Res Int 2018 29;2018:3694362. Epub 2018 May 29.

Department of Cardiovascular Medicine, Division of Electrophysiology, University Hospital Münster, Germany.

Introduction: Cardiomyocyte remodelling in atrial fibrillation (AF) has been associated with both oxidative stress and endoplasmic reticulum (ER) stress and is accompanied by a complex transcriptional regulation. Here, we investigated the role the oxidative stress and ER stress responsive bZIP transcription factor ATF4 plays in atrial cardiomyocyte viability and AF induced gene expression.

Methods: HL-1 cardiomyocytes were subjected to rapid field stimulation. Forced expression of ATF4 was achieved by adenoviral gene transfer. Using global gene expression analysis and chromatin immunoprecipitation, ATF4 dependent transcriptional regulation was studied, and tissue specimen of AF patients was analysed by immunohistochemistry.

Results: Oxidative stress and ER stress caused a significant reduction in cardiomyocyte viability and were associated with an induction of ATF4. Accordingly, ATF4 was also induced by rapid field stimulation mimicking AF. Forced expression of wild type ATF4 promoted cardiomyocyte death. ATF4 was demonstrated to bind to the promoters of several cell stress genes and to induce the expression of a number of ATF4 dependent stress responsive genes. Moreover, immunohistochemical analyses showed that ATF4 is expressed in the nuclei of cardiomyocytes of tissue specimen obtained from AF patients.

Conclusion: ATF4 is expressed in human atrial cardiomyocytes and is induced in response to different types of cell stress. High rate electrical field stimulation seems to result in ATF4 induction, and forced expression of ATF4 reduces cardiomyocyte viability.
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http://dx.doi.org/10.1155/2018/3694362DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5996409PMC
January 2019

Impact of additional tricuspid valve annuloplasty in TOF patients undergoing pulmonary valve replacement.

J Cardiovasc Surg (Torino) 2019 Apr 22;60(2):268-273. Epub 2018 May 22.

Department of Cardiothoracic Surgery, Muenster University Hospital, Muenster, Germany.

Background: Many patients with tetralogy of Fallot (TOF) who underwent surgical correction of their congenital cardiac malformation during infancy develop right ventricular dysfunction and exercise intolerance in the long term. The right ventricle (RV) dilates due to the development of severe pulmonary regurgitation (and secondary tricuspid insufficiency). To reduce RV dilation and improve exercise tolerance pulmonary valve replacement (PVR) is the common therapeutic strategy. Whether concomitant tricuspid valve repair (TVR) is beneficial in these pure volume-overload conditions is still unknown.

Methods: Twenty-eight adults who received surgical PVR were included in the study and perioperative data including operative records, postoperative course and echocardiography before and after surgery was analyzed retrospectively.

Results: Mean age of the patients was 41.1±13.5 years and PVR with Carpentier Edwards Perimount bioprostheses was performed 32.0±9.5 years after initial cardiac surgery. Preoperative echocardiography revealed moderate RV dilation in 60.7% of the patients and severe pulmonary valve regurgitation in 82.3%. Ten patients underwent additional TVR. Indication was purely based on annular dilation (>40 mm), independent from the degree of tricuspid insufficiency. Periprocedural data of both groups did not differ significantly. However, ICU stay was significantly increased in patients who underwent additional TVR (P=0.0420) and these patients developed more complications (P=0.0407) while postoperative echography showed the same recovery of the RV function and diameters, independent of concomitant TVR.

Conclusions: In grown-ups with congenital heart disease surgical PVR with or without TVR is a safe procedure with good short-term outcomes. As the RV remodels after volume reduction, indication for concomitant TVR should be restrictive.
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http://dx.doi.org/10.23736/S0021-9509.18.10385-5DOI Listing
April 2019

Outcomes of aortic valve replacement via partial upper sternotomy versus conventional aortic valve replacement in obese patients.

Interact Cardiovasc Thorac Surg 2018 10;27(4):481-486

Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University Hospital Münster, Münster, Germany.

Objectives: Excellent outcomes after minimally invasive aortic valve replacement (mini-AVR) have been reported. Therefore, mini-AVR has become a popular treatment option in many cardiac surgery centres. However, whether obese patients particularly benefit from mini-AVR remains unclear. The aim of the present study was to evaluate outcomes of AVR performed through partial upper sternotomy compared to AVR through a full sternotomy (full-AVR) in obese patients.

Methods: We retrospectively reviewed the medical records of all patients who underwent isolated AVR at our institution, and 217 consecutive obese [body mass index (BMI) >30 kg/m2] patients were identified. Outcomes of the mini-AVR group were compared with the full-AVR group.

Results: One hundred and twenty-six patients underwent mini-AVR and 91 patients had full-AVR. The mean age and BMI were 69.8 ± 10.4 years and 32.6 ± 3.1 kg/m2 in the mini-AVR group compared to 70.0 ± 10.5 years and 33.1 ± 3.0 kg/m2 in the full-AVR group. Mortality, myocardial infarction, stroke, renal failure and surgical site infections were equivalent. Mini-AVR was associated with decreased ventilation time [6 h (minimum, min 3 h; maximum, max 76 h) vs 8 h (min 3 h; max 340 h); P = 0.004], shorter intensive care unit (ICU) stay [2 days (min 1 day; max 25 days) vs 4 days (min 1 day; max 35 days); P = 0.031] and reduced transfusion requirements (26.5% vs 56.0%; P = 0.004). Total duration of hospital stay as well as postoperative pain levels were comparable.

Conclusions: Patient safety was not affected by mini-AVR. Significant benefits in terms of decreased transfusion requirements, ventilator times and ICU times were found in the mini-AVR group. Consequently, mini-AVR, performed through partial upper sternotomy, should also be routinely offered to obese patients.
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http://dx.doi.org/10.1093/icvts/ivy083DOI Listing
October 2018

Survival results of postoperative coronary angiogram for treatment of perioperative myocardial ischaemia following coronary artery bypass grafting: a single-centre experience.

Interact Cardiovasc Thorac Surg 2018 02;26(2):237-242

Department of Cardiothoracic Surgery, Universitätsklinikum Münster, Münster, Germany.

Objectives: Although perioperative myocardial ischaemia (PMI) is a well-known complication following coronary artery bypass grafting (CABG), standard strategies for its diagnosis and treatment are so far not defined. In this study, we sought to evaluate the impact on survival of postoperative coronary angiogram for management of patients with PMI after CABG.

Methods: Overall, 4028 patients underwent isolated CABG in a single-centre institution between January 2006 and September 2013. A total of 168 (4.2%) patients received postoperative coronary angiogram because of diagnosis of PMI. These patients were matched on the basis of gender, age at surgery and date of surgery, with 336 (1:2 ratio) CABG patients without PMI to determine the impact of the PMI management.

Results: A total of 476 grafts were examined (263 venous grafts, 196 internal mammary artery grafts and 17 radial artery grafts). Almost three-quarters of the 168 PMI (74.4%) patients underwent postoperative coronary angiogram within 24 h of surgery. Normal postoperative coronary angiogram, graft failure and new native vessels occlusion were observed in 23.2%, 52.4% and 24.4% of patients, respectively. A total of 30 (17.9%) patients underwent surgical revision of grafts, whereas 60 (35.7%) patients were treated with percutaneous coronary intervention. Eighteen (10.7%) PMI patients died during the hospital stay compared with 6 (1.8%) patients in the non-PMI group. Survival rates at 7 years were 62.5% in the PMI group and 81.1% in non-PMI group (P < 0.001). After multivariable adjustment PMI (P < 0.001; hazard ratio 3.17, 95% confidence interval 2.12-4.73) turned out to be an independent predictor of mortality on follow-up. Moreover, further subanalysis revealed that delayed postoperative coronary angiogram (>24 h after surgery) was an independent predictor of poorer mid-term survival (P = 0.008; hazard ratio 3.62, 95% confidence interval 1.41-9.33).

Conclusions: PMI after CABG is associated with a significantly poorer survival. A prompt postoperative management must always be considered. Further prospective studies are required to confirm our results.
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http://dx.doi.org/10.1093/icvts/ivx317DOI Listing
February 2018

Safety of Simultaneous Coronary Artery Bypass Grafting and Carotid Endarterectomy Versus Isolated Coronary Artery Bypass Grafting: A Randomized Clinical Trial.

Stroke 2017 10 15;48(10):2769-2775. Epub 2017 Sep 15.

From the Universitätsklinikum Essen, Klinik für Neurologie, Germany (C.W., H.-C.D.); Universitätsklinikum Essen, Zentrum für Klinische Studien (ZKSE), Germany (K.B., C.O.); Universitätsklinikum Essen, Institut für Medizinische Informatik, Biometrie und Epidemiologie (IMIBE), Germany (J.R.); Universitätsklinikum Essen, Klinik für Thorax- und Kardiovaskuläre Chirurgie, Germany (T.H., H.J., S.C.K.); Universitäts-Herzzentrum Freiburg-Bad Krozingen, Klinik für Herz- und Gefäßchirurgie, Germany (F.B.); Universitätsklinikum Jena, Klinik für Herz- und Thoraxchirurgie, Jena, Germany, now Zentralklinik Bad Berka, Germany (M.B.); Westpfalz-Klinikum, Klinik für Thorax-, Herz- und Gefäßchirurgie, Kaiserslautern, Germany (M.D.); Herz- und Gefäßklinik Bad Neustadt/Saale, Klinik für Kardiochirurgie, Bad Neustadt an der Saale, Germany (A.D.); Universitätsklinikum Schleswig-Holstein, Campus Kiel, Klinik für Herz- und Gefäßchirurgie, Kiel, Germany (A.K., M.S.); Universitätsklinikum Münster, Klinik für Herzchirurgie, Germany (S.M.); Herzzentrum Leipzig, Universitätsklinik, Klinik für Herzchirurgie, Leipzig, Germany (F.W.M.); Centrum Kardiovaskulární a Transplantační Chirurgie, Brno, Czech Republic (J.O.); Universitäres Herzzentrum Hamburg, Klinik und Poliklinik für Herz- und Gefäßchirurgie, Germany (B.R.); Universitätsklinikum Gießen und Marburg, Herz-, Kinderherz- und Gefäßchirurgie, Giessen, Germany (P.R.); Universitätsmedizin Göttingen, Abteilung für Thorax-,Herz und Gefäßchirurgie, Göttingen, Germany, now SHG Kliniken Völklingen, Klinik für Herz- und Thoraxchirurgie, Völklingen, Germany (R.S.); Imland Klinik, Gefäß- und Thoraxchirurgie, Rendsburg, Germany (M.S.); Universität Rostock, Klinik und Poliklinik für Herzchirurgie, Germany (G.S.); Johann Wolfgang-Goethe-Universität, Klinik für Thorax-,Herz- und thorakale Gefäßchirurgie, Frankfurt, Germany (A.M.); Medizinische Hochschule Hannover, Klinik für Herz-, Thorax-, Transplantations- und Gefäßchirurgie, Hannover, Germany (M.W.); Herz- und Gefäßzentrum Bad Bevensen, Klinik für Herz-Thorax-Chirurgie, Bad Bevensen, Germany (G.W.-G.); and Universitätsklinikum Jena, Klinische Epidemiologie; Center for Sepsis Control and Care (CSCC), Germany (A.S.).

Background And Purpose: The optimal operative strategy in patients with severe carotid artery disease undergoing coronary artery bypass grafting (CABG) is unknown. We sought to investigate the safety and efficacy of synchronous combined carotid endarterectomy and CABG as compared with isolated CABG.

Methods: Patients with asymptomatic high-grade carotid artery stenosis ≥80% according to ECST (European Carotid Surgery Trial) ultrasound criteria (corresponding to ≥70% NASCET [North American Symptomatic Carotid Endarterectomy Trial]) who required CABG surgery were randomly assigned to synchronous carotid endarterectomy+CABG or isolated CABG. To avoid unbalanced prognostic factor distributions, randomization was stratified by center, age, sex, and modified Rankin Scale. The primary composite end point was the rate of stroke or death at 30 days.

Results: From 2010 to 2014, a total of 129 patients were enrolled at 17 centers in Germany and the Czech Republic. Because of withdrawal of funding after insufficient recruitment, enrolment was terminated early. At 30 days, the rate of any stroke or death in the intention-to-treat population was 12/65 (18.5%) in patients receiving synchronous carotid endarterectomy+CABG as compared with 6/62 (9.7%) in patients receiving isolated CABG (absolute risk reduction, 8.8%; 95% confidence interval, -3.2% to 20.8%; =0.12). Also for all secondary end points at 30 days and 1 year, there was no evidence for a significant treatment-group effect although patients undergoing isolated CABG tended to have better outcomes.

Conclusions: Although our results cannot rule out a treatment-group effect because of lack of power, a superiority of the synchronous combined carotid endarterectomy+CABG approach seems unlikely. Five-year follow-up of patients is still ongoing.

Clinical Trial Registration: URL: https://www.controlled-trials.com. Unique identifier: ISRCTN13486906.
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http://dx.doi.org/10.1161/STROKEAHA.117.017570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5610560PMC
October 2017

Postoperative Complications and Long-Term Results after Primary Cardiac Sarcoma Resection.

Thorac Cardiovasc Surg 2018 11 11;66(8):637-644. Epub 2017 Jun 11.

Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Münster, Münster, Germany.

Background: Primary malignant cardiac tumors rarely occur in clinical care. Little is known about the impact of a parameter on postoperative survival.

Methods: From May 1991 to May 2014, a total of 24 patients underwent surgical treatment of a primary cardiac sarcoma in our center. We analyzed our clinical database retrospectively for information on patient characteristics and treatment data. The follow-up could be completed to 91.7%.

Results: Angiosarcoma and non-otherwise-specified sarcoma were the most common tumor entities. R0 resection was achieved in most cases. Postoperative mortality within the first 30 days was 20.8% ( = 5). In four of these five cases, postoperative low-output cardiac failure was the leading cause of death. The cumulative survival rate was 77.3% after 30 days, 68.2% after 3 months, 50.0% after 6 months, 45.0% after 12 months, and 18.0% after 24 months. The mean survival time in the whole group was 47.0 months. A low tumor differentiation was associated with low mean survival, but this was not statistically significant. Mean survival of sarcoma was higher after R0 resection. There was no significant rate of survival difference regarding the adjuvant therapy concept.

Conclusion: Extended surgery alone or in combination with chemo- and/or radiotherapy may be successful in certain cases and may offer a satisfactory quality of life. The establishment of a multicenter heart tumor register in Germany is necessary to increase the number of cases in studies, get more remarkable study results, and standardize the diagnosis and therapy.
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http://dx.doi.org/10.1055/s-0037-1603790DOI Listing
November 2018

Supporting imaging modalities for improving diagnosis of prosthesis endocarditis: preliminary results of a single-center experience with 18F-FDG-PET/CT.

Minerva Med 2017 Aug 21;108(4):299-304. Epub 2017 Mar 21.

Department of Cardiac Surgery, University Hospital, Münster, Germany.

Background: The aim of the current study was to evaluate the role of PET-CT in the diagnosis of prosthetic valve endocarditis (PVE).

Methods: This is a single-center study including 13 PET/CT examinations performed between February 2009 and March 2016 in 13 patients (76.9% men, mean age 68.1 years, IQR 11.1) because of suspect of PVE. Median interval time between first operation and PET/CT examination was 19.02 months (IQR 85.5). Final diagnosis was made according to pathological criteria (histological and microbiological) of the Duke classification.

Results: Eleven patients (84.6%) presented at the hospital admission positive blood cultures. Eight patients (61.5%) had inconclusive transesophageal echocardiography (TEE). Abnormal 18F-FDG uptake suggestive of active PVE was observed in 10 patients (76.9%), whereas in 3 patients (23.1%) PET/CT did not show any pathological tracer uptake at the level of the previous implanted prostheses. PET/CT revealed 15 (115.4%) new extracardiac findings and one (7.7%) new cardiac focus not previously detected in TEE. All patients underwent redo surgery. Matching the intraoperative findings with those of PET/CT, a total of 10 true positives, 2 true negatives, no false positive and 1 false negative finding was reported. Sensitivity, specificity, and positive and negative predictive values of PET/CT were 90.9%, 100%, 100% and 50% whereas for TEE they were 81.82%, 50%, 81.82%, and 50% respectively. In 61.63% of patients (N. 8) PET/CT and echo findings were concordant. In those cases the diagnosis of endocarditis was confirmed in all.

Conclusions: This study highlights the potential advantages of PET-CT in patients with suspected prosthesis endocarditis. Further prospective evaluations are needed to confirm those preliminary results.
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http://dx.doi.org/10.23736/S0026-4806.17.04976-XDOI Listing
August 2017

Long-term Effects of Remote Ischemic Preconditioning on Kidney Function in High-risk Cardiac Surgery Patients: Follow-up Results from the RenalRIP Trial.

Anesthesiology 2017 May;126(5):787-798

From the Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine (A.Z., H.V.A., C.S., M.K., M.M.) and Department of Cardiac Surgery (S.M.), University Hospital Münster, Münster, Germany; Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania (J.A.K.); Department of Anaesthesiology and Intensive Care Medicine, University Hospital Tübingen, Tübingen, Germany (P.R.); and Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany (D.G.).

Background: In a multicenter, randomized trial, the authors enrolled patients at high-risk for acute kidney injury as identified by a Cleveland Clinic Foundation score of 6 or more. The authors enrolled 240 patients at four hospitals and randomized them to remote ischemic preconditioning or control. The authors found that remote ischemic preconditioning reduced acute kidney injury in high-risk patients undergoing cardiac surgery. The authors now report on the effects of remote ischemic preconditioning on 90-day outcomes.

Methods: In this follow-up study of the RenalRIP trial, the authors examined the effect of remote ischemic preconditioning on the composite endpoint major adverse kidney events consisting of mortality, need for renal replacement therapy, and persistent renal dysfunction at 90 days. Secondary outcomes were persistent renal dysfunction and dialysis dependence in patients with acute kidney injury.

Results: Remote ischemic preconditioning significantly reduced the occurrence of major adverse kidney events at 90 days (17 of 120 [14.2%]) versus control (30 of 120 [25.0%]; absolute risk reduction, 10.8%; 95% CI, 0.9 to 20.8%; P = 0.034). In those patients who developed acute kidney injury after cardiac surgery, 2 of 38 subjects in the remote ischemic preconditioning group (5.3%) and 13 of 56 subjects in the control group (23.2%) failed to recover renal function at 90 days (absolute risk reduction, 17.9%; 95% CI, 4.8 to 31.1%; P = 0.020). Acute kidney injury biomarkers were also increased in patients reaching the major adverse kidney event endpoint compared to patients who did not.

Conclusions: Remote ischemic preconditioning significantly reduced the 3-month incidence of a composite endpoint major adverse kidney events consisting of mortality, need for renal replacement therapy, and persistent renal dysfunction in high-risk patients undergoing cardiac surgery. Furthermore, remote ischemic preconditioning enhanced renal recovery in patients with acute kidney injury.
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http://dx.doi.org/10.1097/ALN.0000000000001598DOI Listing
May 2017

Giant Left Atrial Myxoma: Cause for Position-Dependent Nocturnal Dyspnea and Cardiac Murmur.

Thorac Cardiovasc Surg Rep 2017 Jan;6(1):e1-e2

Department of Cardiothoracic Surgery - Division of Cardiac Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Muenster, Germany.

Primary tumors of the heart are rare. The majority of them are benign, the left atrial myxoma being the most frequent one. Clinical appearance varies from unapparent to life-threatening complications such as stroke, acute heart failure, or even sudden death. Diagnosis and consecutive surgical treatment strongly depend on the clinical symptoms, but their extent does not correlate with the risk for serious complications. Therefore, patients with variable clinical presentation can be especially endangered. Consequent diagnostic and immediate operative therapy is essential.
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http://dx.doi.org/10.1055/s-0036-1597987DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5313258PMC
January 2017

Minimally Invasive Aortic Root Replacement with Valved Conduits through Partial Upper Sternotomy.

Thorac Cardiovasc Surg 2018 06 15;66(4):295-300. Epub 2017 Feb 15.

Division of Cardiac Surgery, Department of Cardiothoracic Surgery, Universitatsklinikum Münster, Münster, Germany.

Background: Minimally invasive surgical access through limited sternotomy reduces trauma and morbidity in cardiosurgical patients. However, until now, it is not the standard access for aortic root replacement. This study details our clinic's experience with minimally invasive implantation of valved conduits through partial upper sternotomy and the comparison to conventional full median sternotomy.

Methods: Between January 2012 and March 2016, a total of 187 patients underwent aortic root replacement with valved conduits in our department. Minimally invasive access through partial upper sternotomy (group A) was performed in 33 patients (9 female, 24 male; mean age: 55.68 ± 13.24 years). Four of these patients received concomitant mitral and tricuspid valve interventions. The results were compared with similar procedures through conventional approach (group B): 25 patients (7 female, 18 male; mean age: 59.09 ± 12.32 years).

Results: In all 33 cases of minimally invasive access and 25 cases of conventional approach, aortic root replacement was successful. Operative times were as follows (in minutes; groups A and B)-cardiopulmonary bypass: 166.12 ± 40.61 and 162.88 ± 45.89; cross-clamp time: 122.24 ± 27.42 and 113.44 ± 22.57, respectively. In both groups, two patients needed postoperative reexploration due to secondary bleeding. One multimorbid patient suffered from postoperative stroke and died on the ninth postoperative day due to heart failure. The observed operation times and clinical results after minimally invasive surgery are comparable to conduit implantation through full median sternotomy.

Conclusions: Partial upper sternotomy is a feasible access for safe aortic root replacement with valved conduits. Nevertheless, minimally invasive aortic root replacement is a challenging operative procedure.
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http://dx.doi.org/10.1055/s-0037-1598196DOI Listing
June 2018

Redo Operation of Recurrent Giant Coronary Artery Aneurysm: Optimizing Surgical Strategy.

Thorac Cardiovasc Surg Rep 2016 Dec 16;5(1):57-59. Epub 2016 Sep 16.

Department of Cardiology, Klinikum Arnsberg, Karolinen-Hospital, Arnsberg-Huesten, Germany.

 Giant coronary artery aneurysms (GCAA) are extremely rare, but they can cause life-threatening complications. Indications for surgical intervention are the occurrence of complications such as fistulas, compression, embolization, or rapid enlargement. The optimal therapeutic approach is still under debate. Until now, there are no publications dealing with the follow-up after surgical treatment. Moreover, the surgical strategy in redo operations has not been described yet.  We report on surgery in a 50-year-old man with a recurrent GCAA after previous dissection and reduction.  Our recommendation is complete resection and bypassing instead of a mere diameter reduction to avoid further progression of the disease.
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http://dx.doi.org/10.1055/s-0036-1586232DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5177433PMC
December 2016

Minimally Invasive Implantation of HeartWare Assist Device and Simultaneous Tricuspid Valve Reconstruction Through Partial Upper Sternotomy.

Artif Organs 2017 May 8;41(5):418-423. Epub 2016 Nov 8.

Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Muenster, Germany.

Left ventricular assist device (LVAD) implantation is a well-established therapy to support patients with end-stage heart failure. However, the operative procedure is associated with severe trauma. Third generation LVADs like the HeartWare assist device (HeartWare, Inc., Framingham, MA, USA) are characterized by enhanced technology despite smaller size. These devices offer new minimally invasive surgical options. Tricuspid regurgitation requiring valve repair is frequent in patients with the need for mechanical circulatory support as it is strongly associated with ischemic and nonischemic cardiomyopathy. We report on HeartWare LVAD implantation and simultaneous tricuspid valve reconstruction through minimally invasive access by partial upper sternotomy to the fifth left intercostal space. Four male patients (mean age 51.72 ± 11.95 years) suffering from chronic heart failure due to dilative (three patients) and ischemic (one patient) cardiomyopathy and also exhibiting concomitant tricuspid valve insufficiency due to annular dilation underwent VAD implantation and tricuspid valve annuloplasty. Extracorporeal circulation was established via the ascending aorta, superior vena cava, and right atrium. In all four cases the LVAD implantation and tricuspid valve repair via partial median sternotomy was successful. During the operative procedure, no conversion to full sternotomy was necessary. One patient needed postoperative re-exploration because of pericardial effusion. No postoperative focal neurologic injury was observed. New generation VADs are advantageous because of the possibility of minimally invasive implantation procedure which can therefore minimize surgical trauma. Concomitant tricuspid valve reconstruction can also be performed simultaneously through partial upper sternotomy. Nevertheless, minimally invasive LVAD implantation is a challenging operative technique.
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http://dx.doi.org/10.1111/aor.12789DOI Listing
May 2017

Early outcomes in re-do operation after acute type A aortic dissection: results from the multicenter REAAD database.

Heart Vessels 2017 May 21;32(5):566-573. Epub 2016 Oct 21.

Department of Cardiac Surgery, San Martino University Hospital, University of Genova, Genoa, Italy.

This study provides early results of re-operations after the prior surgical treatment of acute type A aortic dissection (AAD) and identifies risk factors for mortality. Between May 2003 and January 2014, 117 aortic re-operations after an initial operation for AAD (a mean time from the first procedure was 3.98 years, with a range of 0.1-20.87 years) were performed in 110 patients (a mean age of 59.8 ± 12.6 years) in seven European institutions. The re-operation was indicated due to a proximal aortic pathology in ninety cases: twenty aortic root aneurysms, seventeen root re-dissections, twenty-seven aortic valve insufficiencies and twenty-six proximal anastomotic pseudoaneurysms. In fifty-eight cases, repetitive surgical treatment was subscripted because of distal aortic pathology: eighteen arch re-dissections, fifteen arch dilation and twenty-five anastomotic pseudoaneurysms. Surgical procedures comprised a total of seventy-one isolated proximals, thirty-one isolated distals and fifteen combined interventions. In-hospital mortality was 19.6 % (twenty-three patients); 11.1 % in patients with elective/urgent indication and 66.6 % in emergency cases. Mortality rates for isolated proximal, distal and combined operations regardless of the emergency setting were 14.1 % (10 pts.), 25.8 % (8 pts.) and 33.3 % (5 pts.), respectively. The causes of death were cardiac in eight, neurological in three, MOF in five, sepsis in two, bleeding in three and lung failure in two patients. A multivariate logistic regression analysis revealed that risk factors for mortality included previous distal procedure (p = 0.04), new distal procedure (p = 0.018) and emergency operation (p < 0.001). New proximal procedures were not found to be risk factors for early mortality (p = 0.15). This multicenter experience shows that the outcome of REAAD is highly dependent on the localization and extension of aortic pathology and the need for emergency treatment. Surgery in an emergency setting and distal re-do operations after previous AAD remain a surgical challenge, while proximal aortic re-operations show a lower mortality rate. Foresighted decision-making is needed in cases of AAD repair, as the results are essential preconditions for further surgical interventions.
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http://dx.doi.org/10.1007/s00380-016-0907-xDOI Listing
May 2017

Can Perioperative Right Ventricular Support Prevent Postoperative Right Heart Failure in Patients With Biventricular Dysfunction Undergoing Left Ventricular Assist Device Implantation?

J Cardiothorac Vasc Anesth 2016 Jun 26;30(3):619-26. Epub 2016 Feb 26.

Department for Cardiothoracic Surgery, Division of Cardiac Surgery, University Hospital Münster, Münster, Germany.

Objectives: Depending on the pre-existing condition of the right ventricle (RV), left ventricular assist device (LVAD) implantation may have a detrimental effect on RV function, subsequently leading to right heart failure. This study details the authors' experience with perioperative mechanical RV support in patients with biventricular impairment but primarily scheduled for isolated LVAD implantation.

Design: Retrospective study.

Setting: Two center study, university hospital.

Participants: This study included LVAD recipients with preoperative biventricular impairment who received an additional right ventricular assist device (RVAD) after a failed weaning attempt from cardiopulmonary bypass due to acute RV failure.

Interventions: Outcomes of 25 patients who underwent LVAD and unplanned temporary RVAD implantation were analyzed.

Measurements And Main Results: All patients experienced significant preoperative RV impairment (tricuspid annular plane systolic excursion: 10.2±26.3 mm; right atrium pressure: 17.9±10.4 mmHg) and pulmonary hypertension (pulmonary artery pressure: 54.8±25.7 mmHg). In 15 patients, additional tricuspid valve annuloplasty was performed. Mean duration of temporary RVAD support was 11.1±7.2 days. In 23 patients (92%), the RVAD was removed successfully. None of the patients developed RV failure after RVAD removal. Hospital survival and the 1-year survival rate of the study group were 68% and 56%, respectively.

Conclusions: The results of perioperative RVAD support in LVAD recipients with biventricular dysfunction are encouraging. Temporary RVAD support allows an already compromised RV to become attuned to the hemodynamic conditions after LVAD implantation. This strategy provides patients with preoperative impaired RV function a high likelihood to permanently undergo LVAD support only.
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http://dx.doi.org/10.1053/j.jvca.2016.02.023DOI Listing
June 2016

Mechanical circulatory support for patients with peripartum cardiomyopathy.

J Artif Organs 2016 Sep 22;19(3):305-9. Epub 2016 Mar 22.

Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.

Peripartum cardiomyopathy (PPCM) challenges different disciplines including gynecologists, cardiologists and cardiac surgeons. It is a severe cardiac failure occurring at the end of pregnancy or within the first months after delivery. Urgent intervention is necessary to stabilize hemodynamics with appropriate medication and mechanical assist support. Data of 4 patients with PPCM at a mean age of 28.2 years were analyzed retrospectively. Echocardiography was used to evaluate cardiac function. Despite varying courses of PPCM all women received left ventricular assist devices (LVAD) since their hemodynamics could not be stabilized by medical treatment. Mean gestational week at delivery was 31.5 ± 4.9. Left ventricular ejection fractions of all patients were severely impaired (17.8 ± 3.5 %) before LVAD implantations. After long-term mechanical support (282 and 417 days, respectively) 2 patients were successfully transplanted. Two other females could be weaned from LVAD therapy after 944 and 612 days, respectively. LVAD explanations were performed according to a standardized weaning protocol. Myocardial recovery was confirmed by regular echocardiography, spiroergometry and right heart catheterization. Mechanical assist device support is a surgical strategy either as bridge to transplantation or as bridge to recovery for patients with PPCM.
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http://dx.doi.org/10.1007/s10047-016-0891-zDOI Listing
September 2016

Digital Carotid Compression: A Simple Method to Reduce Solid Cerebral Emboli During Cardiac Surgery.

J Cardiothorac Vasc Anesth 2016 Apr 1;30(2):304-8. Epub 2015 Dec 1.

Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University Hospital of the Westfaelische Wilhelms-University Muenster, Albert-Schweitzer-Campus 1, Muenster, Germany.

Objectives: Serious neurologic injury can be attributed to embolization of solid particles into cerebral vessels during cardiac surgery. Previous studies using transcranial Doppler (TCD) identified arterial cannulation and aortic declamping to be associated with cerebral embolization. The purpose of this study was to investigate the impact of transient compression of the carotid arteries during these maneuvers on the embolic load during cardiac surgery with cardiopulmonary bypass.

Design: Prospective, randomized, clinical trial/pilot study.

Setting: Single-center study at a university hospital.

Participants: Patients with multiple types of procedures were included and they were prospectively, randomly assigned to group I (n = 20, carotid compression during arterial cannulation and aortic declamping) and group II (n = 20, no carotid compression).

Interventions: Bilateral continuous monitoring of the middle cerebral arteries was performed with a multirange, multifreqency transcranial Doppler (DopplerBoxX, DWL, Singen, Germany), allowing for discrimination between solid and gaseous emboli. For aortic cannulation the carotid arteries were compressed for 5 seconds and for declamping for 3 seconds, and microemboli signals were detected within the following 45 seconds.

Measurements And Main Results: A reduction of intraoperative solid emboli was detected in group I compared with group II (26±16 v 38±18; p = 0.04). Looking specifically at the maneuver of arterial cannulation, the observed difference was 0.5±0.8 in group I versus 5.7±5.8 in group II (p<0.0001). During aortic declamping, 6.6±6.2 emboli were encountered in group I and 10.8±5.2 in group II (p = 0.02). The incidence of neurologic events was not significantly different between groups (2 patients in group II had pathologic changes on magnetic resonance imaging).

Conclusions: The data of this preliminary trial demonstrated that transient compression of the carotid arteries during arterial cannulation and aortic declamping led to a decreased number of solid cerebral emboli. Further prospective, randomized clinical studies should be undertaken to investigate the influence of transient carotid artery compression during specific surgical procedures.
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http://dx.doi.org/10.1053/j.jvca.2015.11.017DOI Listing
April 2016

Left Ventricular Assist Devices as Bridge to Cardiac Recovery in Nonischemic Heart Failure: Keeping Weaning from the Device in Mind.

Thorac Cardiovasc Surg 2016 Sep 31;64(6):483-6. Epub 2015 Dec 31.

Department of Cardiothoracic Surgery, University Hospital Münster, Münster, Germany.

A minority of patients on left ventricular assist devices (LVADs) display myocardial recovery raising the question of device explantation. We report a series of seven LVAD patients with nonischemic cardiomyopathy allowing explantation of the VAD. In case of four patients we overview follow-up periods of 4 to 10 years. Remarkably, in three cases device explantation was considered beyond 1 year of LVAD support. Explantation was finally performed after 20 months and more on the device. In light of the scarcity of donor organs we conclude that patients on LVAD support should be evaluated for possible weaning from the device on a regular basis.
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http://dx.doi.org/10.1055/s-0035-1570374DOI Listing
September 2016

Outcome of patients with reduced ankle brachial index undergoing open heart surgery with cardiopulmonary bypass.

Eur J Cardiothorac Surg 2016 May 29;49(5):1457-61. Epub 2015 Oct 29.

Division of Vascular Medicine, Department of Cardiovascular Medicine, University Hospital Münster, Münster, Germany.

Objectives: In open heart surgery using cardiopulmonary bypass, perfusion of the lower extremities is markedly reduced which may induce critical ischaemia in patients with pre-existing peripheral artery disease. Whether these patients have an increased risk for amputation and should better undergo peripheral revascularization prior to surgery remains unclear.

Methods: From 1 January 2009 to 31 December 2010, 785 consecutive patients undergoing open heart surgery were retrospectively included. In 443 of these patients, preoperative ankle brachial index (ABI) measurements were available. The cohort was divided into four groups: (i) ABI < 0.5, (ii) ABI 0.5-0.69, (iii) ABI 0.7-0.89 or (iv) ABI ≥ 0.9. Follow-up data of 413 (93.2%) patients were analysed with regard to mortality and amputations.

Results: The groups differed significantly in terms of age, cardiac risk factors, performed cardiac surgery and renal function. Postoperative delayed wound healing was significantly associated with lower ABI (25.9, 15.2, 27.0 and 9.6% in Groups I-IV, respectively, P = 0.003), whereas 30-day mortality was not significantly higher in patients with lower ABI (0, 4.3, 8.1 and 3.9%, respectively, P = 0.4). Kaplan-Meier models showed a significantly lower long-term survival over 4 years in patients with reduced ABI (P = 0.001, long-rank test) while amputations occurred rarely with only one minor amputation in Group II (P = 0.023).

Conclusions: Patients with reduced ABIs undergoing heart surgery showed more wound-healing disturbances, and higher long-term mortality compared with those with normal ABIs. However, no perioperative ischaemia requiring amputation occurred. Thus, reduced ABIs were not associated with increased peripheral risks in open heart surgery but ABI may be helpful in selecting the site for saphenectomy to potentially avoid delayed healing of related wounds in legs with severely impaired arterial perfusion.
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http://dx.doi.org/10.1093/ejcts/ezv376DOI Listing
May 2016

Pulmonary Bleeding During Right Ventricular Support After Left Ventricular Assist Device Implantation.

J Cardiothorac Vasc Anesth 2016 Jun 14;30(3):627-31. Epub 2015 Jul 14.

Department of Cardiothoracic Surgery, Division of Cardiac Surgery, University Hospital Münster, Münster, Germany.

Objectives: Right heart failure still occurs in up to 20% of patients after implantation of a left ventricular assist device (LVAD). One treatment option for these patients is the implantation of a temporary right ventricular assist device (RVAD). Experimental data suggest that non-pulsatile perfusion of the lungs is associated with an increased rate of pulmonary hemorrhage. The aim of this study was to determine the incidence of pulmonary bleeding complications in these patients.

Design: Observational study.

Setting: Single center, university hospital.

Participants: This study included patients undergoing LVAD implantation for end-stage heart failure and subsequent implantation of a temporary right ventricular support system.

Interventions: In this study, 25 patients who underwent LVAD and additional temporary RVAD implantation were screened for pulmonary bleeding complications.

Measurements And Main Results: The mean Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) level at the time of LVAD implantation was 2.84. All patients experienced severe right ventricular failure (tricuspid annular plane systolic excursion [TAPSE], 10.16±26.3 mm) and severe pulmonary hypertension (right atrial [RA] pressure, 56.21±15.58 mmHg). Average duration of right ventricular support was 11.12±7.20 days, with right ventricular support being administered to 14 patients for more than 7 days. Seventeen patients were weaned successfully from right ventricular support after a mean support duration of 5 days. Five patients developed pulmonary bleeding complications, diagnosed using computed tomography scan and bronchoscopy. All bleeding occurred after postoperative day 7 and was associated with RVAD flow of more than 4 L/min within 24 hours before bleeding occurred.

Conclusions: The data presented in this study suggested that right ventricular support for more than 7 days and a blood flow greater than 4 L/min were associated with pulmonary bleeding complications. This should be taken into consideration when temporary right ventricular support after LVAD implantation is planned.
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http://dx.doi.org/10.1053/j.jvca.2015.07.012DOI Listing
June 2016