Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI) : Joint Consensus Document of the Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V. (ALKK) and cooperating Cardiac Surgery Departments.

Indications for TF-TAVI (transfemoral transcatheter aortic valve implantation) are rapidly changing according to increasing evidence from randomized controlled trials. Present trials document the non-inferiority or even superiority of TF-TAVI in intermediate-risk patients (STS-Score 4-8%) as well as in low-risk patients (STS-Score < 4%). However, risk scores exhibit limitations and, as a single criterion, are unable to establish an appropriate indication of TF-TAVI vs transapical TAVI vs SAVR (surgical aortic valve replacement). The ESC (European Society of Cardiology)/EACTS (European Association for Cardio-Thoracic Surgery) guidelines 2017 and the German DGK (Deutsche Gesellschaft für Kardiologie)/DGTHG (Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie) commentary 2018 offer a framework for the selection of the best therapeutic method, but the individual decision is left to the discretion of the heart teams. An interdisciplinary TAVI consensus group of interventional cardiologists of the ALKK (Arbeitsgemeinschaft Leitende Kardiologische Krankenhausärzte e.V.) and cardiac surgeons has developed a detailed consensus on the indications for TF-TAVI to provide an up-to-date, evidence-based, comprehensive decision matrix for daily practice. The matrix of indication criteria includes age, risk scores, contraindications against SAVR (e.g., porcelain aorta), cardiovascular criteria pro TAVI, additional criteria pro TAVI (e.g., frailty, comorbidities, organ dysfunction), contraindications against TAVI (e.g., endocarditis) and cardiovascular criteria pro SAVR (e.g., bicuspid valve anatomy). This interdisciplinary consensus may provide orientation to heart teams for individual TAVI-indication decisions. Future adaptations according to evolving medical evidence are to be expected. Interdisciplinary consensus on indications for transfemoral transcatheter aortic valve implantation (TF-TAVI).

Reversed root for entirely biological aortic valve and ascending aorta replacement in a patient with endocarditis and mediastinitis.

A 59-year-old patient developed endocarditis with coagulase-negative staphylococci after aortic composite graft replacement and pacemaker implantation. She underwent complete pacemaker removal and tricuspid valve reconstruction. Pus was present in and around the aortic graft. Re-replacement of the aortic root and ascending aorta using only biological material was performed. A 23-mm full root stentless prosthesis (Vascutek Root Elan, Vascutec, Terumo, Leeds, UK) was used for aortic root replacement, and a second 25-mm full root prosthesis with removed cusps implanted in a reversed fashion was used for ascending aorta and proximal aortic arch replacement.

Aortic valve reconstruction: why, when, and how?

After almost 20 years aortic root reconstruction modalities have evolved into reasonable and useful surgical measures. Short and long term results match those of aortic composite replacement. Three major restitution strategies have found widespread acceptance: Root replacement with valve reimplantation (David-Procedure), root remodeling (Yacoub-procedure), or commissural resuspension. In the wake of these modalities also isolated aortic valve repair techniques have found renewed interest in order to broaden the indication for reconstructive surgery. Some euphemistic and hence biased interpretation, however, should be considered when looking at the clinical results. Reimplantation and remodeling procedures as well as several valve repair maneuvers are technically demanding unfolding their potential only in the hands of an experienced surgeon. Definite guidelines regarding the appropriate method of restitution required to serve best in the patient's individual situation are not yet at hand although they are about to emerge.

[Bedside thrombelastography. Cost reduction in cardiac surgery]. / "Bedside"-Thrombelastographie. Kostenreduktion in der Herzchirurgie.

BACKGROUND: Demographic changes and aggressive medication with platelet aggregation inhibitors have resulted in a marked increase in blood and coagulation product expenditure and costs in cardiac surgery. We analyzed the bedside coagulation test (ROTEM) in order to verify clot forming quality and to find a cost-effective treatment algorithm. PATIENTS AND METHODS: Annual treatment costs of all cardiosurgical patients were retrospectively analyzed before (729 patients) and after (693 patients) implementation of the bedside ROTEM test. Cumulative numbers and costs of platelet concentrates (PltC), fresh frozen plasma (FFP), red blood cell units (RBC), and the coagulation factors prothrombin complex concentrates (PCC), recombinant factor VIIa (rFVIIa), factor XIII (FXIII), and fibrinogen were assessed. Average monthly numbers and costs were compared. The number of rethoracotomies and early mortality were assessed and compared in both periods. RESULTS: After ROTEM implementation cumulative RBC expenditure showed a 25% decrease and PltC a 50% decrease. FFP expenditure remained unchanged. PCC, FXIII were markedly reduced (-80%) while rFVIIa was entirely omitted. Fibrinogen, however, showed a two-fold increase. Cumulative average monthly costs of all blood products decreased from 66,000 EUR to 45,000 EUR (-32%). Coagulation factor average monthly costs decreased from 60,000 EUR to 30,000 EUR (-50%) yielding combined savings of 44%. In contrast, average monthly costs for ROTEM were 1,580 EUR. The total number of rethoracotomies decreased from 6.6% to 5.5% while early mortality (5.9%; 6.0%) remained stable. CONCLUSIONS: Cumulative costs for treatment of perioperative coagulation disorders were reduced by bedside ROTEM analysis to achieve a selective substitution management. Saved costs for blood and coagulation products clearly outweighed the expenses of ROTEM. Adequate differential coagulation management can therefore be cost-effective.

Opening and closure characteristics of different types of stented biological valves.

BACKGROUND: In an increasingly senescent population stented biological valves have regained renewed popularity because of the absence of anticoagulation, while the stented design allows for safe and easier implantation. Constructed bovine pericardial valves as well as valves with porcine cusps are used, both of which exhibit good clinical results although degeneration still appears. While clinical hemodynamic studies did not show particular differences between both valves types, the opening and closure behavior of native cusps and artificially constructed pericardial leaflets is different. It is unclear whether these phenomena account for differences in load and stress which may influence onset and course of degeneration. MATERIAL AND METHODS: Edwards Perimount (EP) and Medtronic Mosaic (MM) heart valves with diameters of 21 mm, 23 mm, and 25 mm were investigated in a pulse duplicator. Movements of the valves were visualized with a high-speed camera (1000 frames/sec). Mean transvalvular gradient (mm Hg), dissipated power (mW), and power transfer by stretching (mW), mean orifice area (mm2), opening time (ms), and closure time (ms) were analyzed in a range of cardiac outputs from 1.4 l/min to 6.3 l/min and 70 beats per minute. RESULTS: Closure times were generally longer than opening times for both valve types. Opening time of EP valves was longer than opening time of the MM valves of the same size (EP23: 31.2 +/- 2.5 ms; MM23: 12.7 +/- 0.1 ms). With respect to closure times, however, there were no marked differences between all valves (EP23: 69.3 +/- 2.0 ms; MM23: 63.2 +/- 6.3 ms). Smaller sized Perimount valves exhibited lower mean transvalvular gradients than Mosaic valves of the same size (EP23: 7.21 +/- 0.07 mm Hg; MM23: 10.5 +/- 0.15 mm Hg). In larger sizes these differences diminished. Power transfer to the valve's structures was significantly enhanced in EP valves (EP23: 134 +/- 1.3 mW; MM23: 64 +/- 0.9 mW). CONCLUSIONS: While valves with constructed pericardium showed lower mean transvalvular gradients, particularly in the smaller sizes, this valve type exhibited alterations of movement performance in contrast to porcine valves. It can be speculated that constant power transfer to the valve's structures may result in an earlier degeneration because of the impact of the increased load and stress on the suspension apparatus of the constructed pericardial leaflets.

Different tilting disc valves show similar rotation-dependent impairment in hemodynamic performance under a tilted implantation position.

BACKGROUND: Aortic annulus calcification can promote tilted implantation of mechanical valves. This study evaluates the hemodynamics of tilting disc valves under this condition. METHODS: 23 mm and 25 mm Ultracor (UC) and Medtronic-Hall-Easy-Fit (MH) valves were investigated in a pulse-duplicator under physiological conditions. Mean pressure gradient (dP(mean)), systolic energy loss (dW(sys)), effective orifice area (EOA), closure (V(Cl)), leakage (V(L)), and total regurgitation volume (V(R)) were assessed. Valves were independently positioned at five axial rotations (0 - 180 degrees , zero defined as major orifice facing the top of the "tilt-ramp") and three tilt angles (0 degrees, 10 degrees, 20 degrees) by lifting the prosthesis in the noncoronary sinus. RESULTS: Diameter-enhanced MH valves exhibited a better systolic performance but a higher regurgitation than corresponding UC valves. Moderate tilting showed a rotation-independent increase in dP(mean) and dW(sys) and a decrease in V (R) and EOA with no fundamental differences between valve types. Further tilting caused small additional changes at 90 - 180 degrees rotation. At 0 degrees rotation, however, dramatic regurgitation occurred throughout. CONCLUSION: Tilting worsened systolic performance regardless of valve type. It should therefore be avoided. Due to extensive regurgitation at 0 degrees rotation, this position should be corrected whenever tilting is inevitable.

Bland-White-Garland syndrome. Surgical treatment using a minimal-invasive approach.

We report the surgical treatment of a Bland-White-Garland syndrome (BWG-syndrome) of adult type in a 61-year old female patient. Coronary catheterization revealed an anomalous origin of the left coronary artery from the trunk of the pulmonary artery. Based on excellent collateral perfusion of the artery from the right coronary artery, ligation near its origin from the pulmonary artery was attempted via a minimally-invasive approach. No saphenous vein bypass was implanted, no reimplantation of the anomalous vessel in the aorta was performed. The patient recovered uneventfully without signs of ischemia. Appearance of BWG-syndrome in adults is very rare, especially without symptoms of myocardial ischemia. The different modalities of the treatment of these syndromes in adult patients are often debated. In this case, closure without revascularisation appeared to be appropriate.

Outcome of patients after cardiac surgery transferred to other hospitals following prolonged intensive care stay.

BACKGROUND: The steady rise in complex cardiac procedures as well as the increase in comorbidity often result in a prolonged intensive care unit (ICU) stay. As a consequence, considerable numbers of patients have to be transferred to other hospitals so that the primary institution can maintain its capacity. The purpose of this study was to investigate the outcome of these patients. METHODS: 1,175 consecutive patients underwent various open heart procedures. 115 patients (9.8 %) requiring prolonged ICU treatment were retrospectively analyzed. 74 patients (EuroSCORE 8.1) underwent transferral to either rehabilitation units with ventilation capacity, multidisciplinary ICUs, or cardiac ICUs. 41 patients (EuroSCORE 7.9) remained in our hospital. Morbidity, mortality, and clinical condition were assessed and compared. RESULTS: Transferred patients exhibited an overall mortality of 38 % compared to only 17 % in patients who remained. Mortality was 81 % in rehabilitation units, 30 % in multidisciplinary ICUs, and 16 % in cardiac ICUs. 66 % of the survivors among the transferred patients showed significantly impaired clinical condition (NYHA III-IV) compared to 33 % who showed a good postoperative condition (NYHA I-II). The patients who remained exhibited 44 % NYHA III-IV and 56 % NYHA I-II. CONCLUSION: Transferral of patients after prolonged intensive care stay to external hospitals carries significant risks for early death and impaired outcome. However, transferral to cardiac ICUs appears to be an adequate option. Further studies may identify potential subgroups of patients who do not benefit from transferral.

Comparison of pulsatile and nonpulsatile perfusion of the lung in an extracorporeal large animal model.

OBJECTIVE: Extracorporeal lung-perfusion models are widely used to evaluate pulmonary preservation techniques and reperfusion injury. However, these models mainly depend on nonpulsatile flow, which is not physiological and can subsequently lead to pulmonary edema. Observation in a standardized setting and reliability of functional and structural data assessment are therefore limited. To overcome these limitations we developed a new extracorporeal large animal lung perfusion model utilizing pulsatile flow to perfuse the pulmonary vasculature. METHODS: Lungs of juvenile domestic pigs were in situ preserved with 2 liters Perfadex and stored for 3 h at 10 degrees C. Thereafter, reperfusion of the lung was performed in an extracorporeal blood perfusion circuit employing either a modified roller pump with pulsatile module (300 ml/min; pulsation rate 90/min) or a standardized roller pump with continuous flow (30 ml/min). Ventilation was performed with physiologic room air (350 ml; 16/min) for 1 h. Pulsatile and nonpulsatile perfusion was performed in 2 groups (group NP: nonpulsatile; group P: pulsatile flow, n = 7) during reperfusion. Peak inspiratory pressure (PIP), mean pulmonary artery pressure (PAP), and oxygenation capacity (DeltaPO(2)) were continuously measured. For control of the effectiveness of the pulsatile perfusion pressure waveforms were obtained directly from the native pulmonary artery of both groups. Malondialdehyde (MDA) as a parameter for lipid peroxidation and endothelial cell damage was assessed at 10, 30 and 50 min reperfusion. At the end of the study, pulmonary water content was assessed by means of wet-to-dry ratio (W/D ratio). The tissue was further processed for microscopic analysis. RESULTS: PIP increased significantly in both groups during reperfusion. Mean PAP in both groups increased to 60 mm Hg after 20 min followed by a decrease after 60 min to 40 mm Hg. Pressure waveforms of the pulmonary artery showed sufficient pulsatility in the pulmonary vasculature with a systolic/diastolic pressure difference of 15 mm Hg whereas the pressure difference was 3-5 mm Hg in the nonpulsatile group. DeltaPO(2) was stable in groups NP and P during reperfusion (30 min: NP: 66.4 (62.2-88) mm Hg; P: 74.8 (65-81.7) mm Hg) without any statistically significant differences between the groups. MDA in group NP decreased over the reperfusion period from 6.2 (3.3-6.3) microM at 10 min to 5.2 (3.2-6.1) microM at 50 min, whereas in group P the level increased and was significantly higher after 50 min reperfusion compared to group NP [6.6 (6.1-9.2) microM at 50 min; p = 0.016]. W/D ratio was 6.7 (6.3-7.0) in group NP and 6.8 (6.3-7.6) in group P. Light microscopy evaluation showed no differences between both groups regarding severity of intra-alveolar and interstitial edema and numbers of intra-alveolar, intracapillary and interstitial granulocytes. CONCLUSION: Although effective pulsatile perfusion of the pulmonary vasculature was achieved by means of a modified roller pump, this measure obviously did not improve functional parameters nor did it significantly reduce the edema formation after 3 h ischemia in this extracorporeal lung perfusion model. The use of pulsatile perfusion is therefore not mandatory in the extracorporeal setting of a large animal lung perfusion model.

Value of positron emission tomography for lung cancer staging.

OBJECTIVE: The therapeutic strategy in non-small-cell lung cancer (NSCLC) requires exact staging of tumour invasion (T) as well as differentiation between ipsi- and contralateral lymph node invasion (N1/2 vs N3). [18F]FDG-positron emission tomography (FDG-PET) has been shown to detect invaded N with high accuracy while correct determination of T appears to be unclear. The purpose of this prospective study was to evaluate benefit and necessity of 18FDG-PET as an additive to conventional staging modalities. METHODS: Forty patients with suspected non-small-cell lung cancer (NSCLC) were staged by means of computed tomography (CT), bronchoscopy, mediastinoscopy and bone scintigraphy. Additionally, attenuation corrected FDG-PET of the thorax was performed pre-operatively for analysis of T and N topography. After surgical resection with radical lymphadenectomy T and N staging results of CT and PET were compared with the pathological diagnoses. Specificity, sensitivity, positive predictive value and accuracy of CT and PET were calculated. RESULTS: Twenty three squamous cell carcinomas, 14 adenocarcinomas, and three non-malignant tumours were found. Accuracy of CT-T was 0.75 and of PET-T 0.78; accuracy of CT-N was 0.78 and of PET-N 0.80. By combination of CT-T and PET-T accuracy was 0.88. Combination of CT-N and PET-N yielded an accuracy of 0.90. In two out of three cases, PET correctly determined T0. In two cases non-malignant inflammatory lymph nodes were falsely staged as malignant by PET. CONCLUSIONS: Adequate pre-operative T- and N-staging is possible with both CT and FDG-PET. Accuracy can be improved by combination of CT and FDG-PET. FDG-PET is superior to CT in order to differentiate between malignant and benign tumours. However, acute inflammation can mimic malignant lymph node invasion. FDG-PET is justified as a supporting staging measure in cases presenting unclear differentiation between N2 and N3 after conventional staging and is helpful in cases with unclear cell type of the primary tumour.

[Hybrid 3-D rendering of the thorax and surface-based virtual bronchoscopy in surgical and interventional therapy control]. / Hybride 3D-Visualisierung des Thorax und oberflächenbasierte virtuelle Bronchoskopie in der operativen und interventionellen Therapiekontrolle.

PURPOSE: The aim of this study was to demonstrate the possibilities of a hybrid rendering method, the combination of a color-coded surface and volume rendering method, with the feasibility of performing surface-based virtual endoscopy with different representation models in the operative and interventional therapy control of the chest. MATERIAL AND METHOD: In 6 consecutive patients with partial lung resection (n = 2) and lung transplantation (n = 4) a thin-section spiral computed tomography of the chest was performed. The tracheobronchial system and the introduced metallic stents were visualized using a color-coded surface rendering method. The remaining thoracic structures were visualized using a volume rendering method. For virtual bronchoscopy, the tracheobronchial system was visualized using a triangle surface model, a shaded-surface model and a transparent shaded-surface model. RESULTS: The hybrid 3D visualization uses the advantages of both the color-coded surface and volume rendering methods and facilitates a clear representation of the tracheobronchial system and the complex topographical relationship of morphological and pathological changes without loss of diagnostic information. Performing virtual bronchoscopy with the transparent shaded-surface model facilitates a reasonable to optimal, simultaneous visualization and assessment of the surface structure of the tracheobronchial system and the surrounding mediastinal structures and lesions. CONCLUSIONS: Hybrid rendering relieve the morphological assessment of anatomical and pathological changes without the need for time-consuming detailed analysis and presentation of source images. Performing virtual bronchoscopy with a transparent shaded-surface model offers a promising alternative to flexible fiberoptic bronchoscopy.

Correction of anterior thoracic wall deformities: improved planning by means of 3D-spiral-computed tomography.

Surgical correction of anterior thoracic wall deformities is an extensive procedure with considerable operative trauma. The procedure can be markedly supported by means of preoperative 3D spiral-computed tomography for the purpose of improved preoperative planning in order to avoid unnecessary tissue mobilization. It is also helpful to enhance the patients' comprehension regarding the operative requirements.

Influence of high molecular dextrans on lung function in an ex vivo porcine lung model.

BACKGROUND: Extracellular preservation solutions utilizing high molecular agents can reduce intracellular edema during ischemia/reperfusion in lung transplantation. A solution of 40,000 dalton molecular weight (DMW) has already been clinically established (Perfadex). However, it is unclear whether dextrans of this particular size represent the optimal additive for lung preservation solutions. MATERIALS AND METHODS: In a new ex vivo porcine lung model, lungs were each preserved with low-potassium solutions containing 5% dextran with 90,000 DMW (Dex 90) and 160,000 DMW (Dex 160) and with Perfadex (40,000 DMW). After 24 h of cold ischemia, reperfusion was performed employing a roller pump with a pulsatile module. Lungs were perfused with deoxygenated perfusate and ventilated with room air. The oxygenation capacity (Delta pO(2)), peak inspiratory pressure (PIP), and mean pulmonary artery pressure (PAP) were monitored for 60 min. Net weight gain (NWG) and wet-to-dry ratio (W/D ratio) were determined. Free-radical generation was assessed by measuring malondialdehyde (MDA) at 10, 30, and 50 min. RESULTS: PIP and PAP increased in all groups significantly during reperfusion. However, Dex 160-perfused lungs exhibited significantly higher values than those with Dex 90 and Perfadex. Perfadex showed the highest Delta pO(2) throughout the entire reperfusion, while Delta pO(2) was slightly reduced in Dex 160 and significantly lower in Dex 90. In Perfadex the lowest water content was observed assessed by NWG and W/D ratio. The highest MDA values were observed in Dex 90, followed by Dex 160, while the lowest values were seen in Perfadex. CONCLUSIONS: Preservation of the lung with Perfadex exhibited superior postischemic function in contrast to preservation solutions containing dextrans with a higher molecular weight.

A patient with five primary tumours of the aerodigestive tract and the kidney. The Interdisciplinary Tumour Board, Tübingen.

We report the case of a 65-year-old male who developed an oropharyngeal carcinoma, an oesophageal carcinoma and two primary bronchial carcinomas in combination with a renal cell carcinoma as an additional primary entity. By means of an aggressive diagnostic regimen including radiological and nuclear imaging techniques all carcinomas were detected early and could be treated with curative intention.

Successful weaning of a transplanted heart from biventricular assist device.

Exceptionally few cases worldwide have survived weaning from a biventricular assist device following heart transplantation in contrast to those who underwent early retransplantation. We present a successful outcome after biventricular assist device implantation following initial biventricular failure after heart transplantation. Weaning could be performed after 1 week, although pulmonary vascular resistance remained markedly elevated.

Preservation of intraalveolar surfactant in a rat lung ischaemia/reperfusion injury model.

Ischaemia/reperfusion (I/R) injury, a major problem in clinical lung transplantation, is associated with surfactant dysfunction. The present study aimed to test the hypothesis that preservation related improvements in post-ischaemic lung function are associated with improved ultrastructural preservation of pulmonary surfactant. Rat lungs were flush perfused with modified Euro-Collins solutions (ECS), stored for 2 h at 4 degrees C, and reperfused for 40 min. Lungs were preserved with conventional (ECS 115: 115 mmol x L(-1) K+), medium-K+ (ECS 40: 40 mmol x L(-1) K+), or low-K+ (ECS 10: 10 mmol x L(-1) K+) ECS. Functional parameters were monitored during reperfusion (n=10 per group). After reperfusion, left lungs were prepared for electron microscopical and stereological analysis of surfactant (n=5 per group). In all three experimental groups notable I/R injury developed which was lowest in ECS 40 as indicated by significantly less intraalveolar oedema, higher perfusate oxygenation, and lower peak inspiratory pressure. This was associated with a significantly superior preservation of the ultrastructure of the surface active surfactant subtype tubular myelin in ECS 40 compared with ECS 115 and ECS 10. Stereological analysis revealed that the relative amount of tubular myelin was highest in ECS 40 (mean+/-SEM; 6.2+/-0.8%) compared with ECS 115 (3.0+/-1.0%) and ECS 10 (2.7+/-1.6%). Analysis of surfactant in its natural location within the organ showed that the severity of ischaemia/reperfusion injury correlates with differences in intraalveolar surfactant composition. Improved post-ischaemic respiratory function achieved by medium-K+ Euro-Collins solution is associated with superior ultrastructural preservation of tubular myelin. It is concluded that the integrity of surface active tubular myelin represents an important criterion for the assessment of lung preservation quality.

Significance of cyclic adenosine monophosphate and nitroglycerin in ET-Kyoto solution for lung preservation.

BACKGROUND: We previously demonstrated that the supplement of both dibutyryl cyclic adenosine monophosphate (db-cAMP) and nitroglycerin to the conventional ET-Kyoto solution improved lung preservation significantly. However, the significance of each component in lung preservation remained unclear. We examined the efficacy of the two components on lung preservation in the current study. METHODS: Rat lung grafts (eight per group) were studied in an isolated lung perfusion model. Group 1 grafts were flushed and preserved with ET-Kyoto solution containing 2 mmol/L of db-cAMP. Group 2 grafts were flushed and preserved with ET-Kyoto solution containing 100 mg/L of nitroglycerin. In group 3, the grafts were flushed and preserved with ET-Kyoto solution containing neither db-cAMP nor nitroglycerin as control group. After 4-hour cold storage, the lung grafts were reperfused for 50 minutes. RESULTS: The lung grafts in groups 1 and 2 showed significantly better lung function after reperfusion than those in group 3 with regard to arterial oxygen tension, shunt fraction, peak inspiratory airway pressure, mean pulmonary arterial pressure, and pulmonary vascular resistance. The supplementation of db-cAMP improved especially the pulmonary arterial pressure and pulmonary vascular resistance, while the supplementation of nitroglycerin improved especially the oxygenation and airway pressure of the grafts. CONCLUSIONS: Both of db-cAMP and nitroglycerin had beneficial effects on lung preservation and are essential to the ET-Kyoto solution. There was a difference between the two components in the effects on preserved lungs.

The significance of preformed aprotinin-specific antibodies in cardiosurgical patients.

UNLABELLED: Acute hypersensitivity reactions are serious complications of reexposure to aprotinin. Previous contact via infusions or fibrin tissue adhesives can induce specific antibodies. In this study, we aimed to elucidate the preoperative prevalence of aprotinin-specific antibodies in patients scheduled for cardiac operations. Sera of 520 consecutive cardiosurgical patients were collected preoperatively and screened retrospectively for aprotinin-specific IgG using a standard enzyme-linked immunosorbent assay (ELISA). Positive sera were analyzed also for aprotinin-specific IgA (ELISA) and IgE (fluorescence enzyme immunoassay). The histories of all patients were reviewed with focus on aprotinin preexposure. Of 520 patients, 22 (4%) had specific IgG. Only three of these had a documented aprotinin preexposure. Of 448 patients exposed to aprotinin intraoperatively, 15 had preformed specific antibodies. The only patient presenting with severe anaphylaxis was positive for both IgG and IgE, and had a recent IV preexposure in cardiovascular surgery. The presence of aprotinin-specific IgG alone seems not to induce adverse reactions on exposure. Exposure history alone is not sensitive enough to identify patients with aprotinin-specific antibodies. IMPLICATIONS: Anaphylaxis on IV reexposure to aprotinin is a medical emergency. The clinical significance of preformed aprotinin-specific IgG remains questionable, whereas preformed IgE was present in the only patient who suffered from severe anaphylaxis on reexposure to aprotinin. Preformed antibodies are not reliably predicted by exposure history.