First Use of a New Extracorporeal Membrane Oxygenation System in COVID19-Associated Adult Respiratory Distress Syndrome: The MobyBox Device.

In late 2020, during the second wave of COVID-19 in Germany, we started using the MobyBox, which is a novel fully pneumatically driven ECMO device, on a regular basis to meet the increasing demand for ECMO therapy. In this case series, we performed a retrospective chart review of seven patients with severe COVID-19-related acute respiratory distress syndrome (ARDS) requiring veno-venous (vv)-ECMO support with the MobyBox. During ECMO treatments we have observed no disadvantages in comparison to conventional ECMO systems. There were no system failures or adverse events directly attributable to the MobyBox system. Our data support that providing vv-ECMO with the MobyBox device is safe and feasible. Furthermore, our findings suggest that the MobyBox device might represent an advantage in terms of biocompatibility. Therefore, more data on this issue is needed to better understand how the pneumatically driven pump affects cellular blood components.

Objective method to evaluate the competency of residents in cardiac surgery.

OBJECTIVES: Cardiac surgery training has become more challenging as patients and their diagnoses become more complex. Our goal was to develop a multicategorical assessment model for evaluating residents in cardiac surgery. This model is intended to ensure goal-directed progress in their training as well as to recognize and support their surgical talents. METHODS: We developed a new questionnaire in a multistage, 3-round process based on the Delphi method 'estimate-talk-estimate', using 55 competencies, including 38 general and 17 domain-specific competencies. Each competency is evaluated with 1 or more questions, to which 1 (not competent) to 6 (very competent) points can be chosen as an answer. RESULTS: The resulting model achieved 2 main goals: first, presenting a well-defined competency list for cardiac surgical training and second, providing an objective and realistic evaluation of trainees' abilities. Residents were assessed by all trainers to achieve a high level of objectivity. CONCLUSIONS: This evaluation model is highly objective, because residents are evaluated by multiple trainers. It allows individual support and enables better transparency in residency training. Talents and skills are evaluated, recognized and adopted as a base for individual feedback and personalized training programmes.

Emergent surgical pulmonary embolectomy in a pregnant woman: case report and literature review.

Acute pulmonary embolism is a leading cause of death during pregnancy and delivery in the United States. We describe the case of a 25-year-old woman who presented in cardiogenic shock in week 38 of her first pregnancy. After the emergent cesarean delivery of a healthy male neonate, the mother underwent immediate surgical pulmonary embolectomy. We confirmed the diagnosis of pulmonary embolism intraoperatively by means of transesophageal echocardiography and removed large clots from the patient's pulmonary arteries. Mother and child were doing well, 27 months later. In addition to presenting our patient's case, we discuss the other relevant reports and the options for treating massive pulmonary embolism during pregnancy.

Familial ankyloglossia (tongue-tie): a case report.

Ankyloglossia (tongue-tie) is a congenital anomaly with a prevalence of 4-5% and characterized by an abnormally short lingual frenulum. For unknown reasons the abnormality seems to be more common in males. The pathogenesis of ankyloglossia is not known. The authors report a family with isolated ankyloglossia inherited as an autosomal dominant or recessive trait. The identification of the defective gene(s) in these patients might reveal novel information on the pathogenesis of this disorder.

Mid-term results of a modified arterial switch operation using the direct reconstruction technique of the pulmonary artery.

BACKGROUND: There is ongoing discussion as to whether it is beneficial to avoid pulmonary sinus augmentation in the arterial switch operation. We report a single-surgeon series of mid-term results for direct pulmonary artery anastomosis during switch operation for transposition of the great arteries (TGA). METHODS: This retrospective study includes 17 patients with TGA, combined with an atrial septal defect, patent foramen ovale or ventricular septal defect. Patient data was analyzed from hospital charts, including operative reports, post-operative course, and regular follow-up investigations. The protocol included cardiological examination by a single pediatric cardiologist. Echocardiographic examinations were performed immediately after arrival on the intensive unit, before discharge, and then after three, six, and 12 months, followed by yearly intervals. Pulmonary artery stenosis (PAS) was categorized into three groups according to the Doppler-measured pulmonary gradient: grade I (trivial stenosis) = increased pulmonary flow with a gradient below 25 mm Hg; grade II (moderate stenosis) = a gradient ranging from 25 to 49 mm Hg; and grade III (severe stenosis) = a gradient above 50 mm Hg. Follow-up data was available for all patients. The length of follow-up ranged from 1.2 to 9.7 years, median: 7.5 years (mean 6.1 years ± 14 months). RESULTS: During follow-up, 12 patients (70.6%) had no (or only trivial) PAS, five patients (29.4%) had moderate stenosis without progress, and no patient had severe PAS. Cardiac catheterization after arterial switch operation was performed in 11 patients (64.7%) and showed a good correlation with echocardiographic findings. During follow-up there was no reintervention for PAS. CONCLUSIONS: Direct reconstruction of the neo-pulmonary artery is a good option in TGA with antero-posterior position of the great vessels, with very satisfactory mid-term results.

Cardiac myxomas: short- and long-term follow-up.

BACKGROUND: Cardiac myxomas are the most frequently encountered benign intracardiac tumors, that, if left untreated, are inexorably progressive and potentially fatal. Patients with cardiac myxoma can be treated only by surgical removal. This study summarizes our experience over 22 years with these tumors. METHODS: Fifty seven patients (M/F: 14/43, age: 57.9 +/- 14.6 years) with cardiac myxomas underwent surgical resection at our institution. There were 82.4% left atrial myxomas, 14.0% right atrial myxomas, 3.6% biatrial myxomas. The duration of symptoms prior to surgery ranged from 6 to 1,373 days (median 96 days). The surgical approach comprised complete wide excision. The diagnostic methods, incidence of thromboembolic complications, valve degeneration, surgical repair techniques, recurrence and re-operation were reviewed and the Kaplan-Meier survival curve was calculated. RESULTS: There were no in-hospital deaths. Hospital stay amounted to a mean of 13.7 +/- 6.9 days. Late follow-up was available for 54 (94.7%) patients for a median 7.5 years after surgery (23 days to 21.4 years). Fifty two patients are alive, while five patients had died after a mean interval of 6.3 years. Cause of death was cardiac in 40% of the patients (n = 2) and non-cardiac in the other 60% (n = 3). CONCLUSIONS: Surgical excision of cardiac myxoma carries a low operative risk and gives excellent short-term and long-term results. Surgical excision of the tumor appears to be curative, with few recurrences at long-term follow-up. After diagnosis, surgery should be performed urgently, in order to prevent complications such as embolic events or obstruction of the mitral orifice. Follow-up examination, including echocardiography, should be performed regularly.

Endovascular aortic arch repair after aortic arch de-branching.

PURPOSE: Conventional surgical therapy of aortic arch aneurysms consists of aortic arch replacement requiring cardiopulmonary bypass and deep hypothermic circulatory arrest. This method is associated with significant morbidity and mortality, mainly due to neurologic complications and the sequelae of deep hypothermic circulatory arrest. Thus, it makes sense to work on developing less invasive surgical techniques. DESCRIPTION: Surgical aortic arch de-branching is required before the supra-aortic vessels can be safely covered by an endovascular stent graft. We describe how the supra-aortic vessels can best be revascularized, followed by complete coverage of the aortic arch with endovascular stent grafts. EVALUATION: We hereby present our case selection criteria, preoperative work-up, and surgical approach for aortic arch de-branching with supra-aortic revascularization, followed by complete coverage of the aortic arch by endovascular stent grafting. This technique's safeguards and pitfalls are described for a cohort of 26 patients. CONCLUSIONS: Endovascular aortic arch repair after aortic arch de-branching has the potential to lower the morbidity and mortality rates in patients with aortic arch diseases.

Upregulation of phospholipase d expression and activation in ventricular pressure-overload hypertrophy.

Evidence for a role of phospholipase D (PLD) in cellular proliferation and differentiation is accumulating. We studied PLD activity and expression in normal and hypertrophic rat and human hearts. In rat heart, abdominal aortic banding (constriction to 50% of original lumen) caused hypertrophy in the left ventricle (as shown by weight index and ANP expression) by about 15% after 30 days without histological evidence of fibrosis or signs of decompensation and in the right ventricle after 100 days. The hypertrophy was accompanied by small increases of basal PLD activity and strong potentiation of stimulated PLD activity caused by 4beta-phorbol-12beta,13alpha-dibutyrate (PDB) and by phenylephrine. The mRNA expressions of both PLD1 and PLD2 determined by semiquantitative competitive RT-PCR were markedly enhanced after aortic banding. In the caveolar fraction of the rat heart, PLD2 protein determined by Western blot analysis was upregulated in parallel with the expression of caveolin-3. A similar induction of PLD mRNA and protein expression was observed in hypertrophied human hearts of individuals (39-45-year-old) who had died from non-cardiac causes. In conclusion, PLD1 and PLD2 expressions were strongly enhanced both in rat and human heart hypertrophy, which may be responsible for the coincident potentiation of the PLD activation by alpha-adrenoceptor and protein kinase C stimulation. These results are compatible with a significant role of PLD activation in cell signaling of ventricular pressure-overload hypertrophy.

Aortic valve papillary fibroelastoma.

Cardiac papillary fibroelastoma (CPF) is a rare primary benign cardiac tumor. Before the use of echocardiography, the lesion was identified at autopsy or incidentally during cardiac surgery. CPF is the third most common primary cardiac tumor after atrial myxoma and lipoma, and is the most common tumor of the valvular endothelium. Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) permit diagnosis of the tumor in living patients. CPF may be the cause of cerebrovascular or cardiac ischemia due to embolization or occlusion of the vascular ostia. Embolic material may arise from fragments of the tumor itself, or from surrounding thrombus. The case is reported of a patient with CPF of the aortic valve in whom TEE diagnosis was conducted and the tumor removed surgically.

Comparison of cardiac troponin I versus T and creatine kinase MB after coronary artery bypass grafting in patients with and without perioperative myocardial infarction.

BACKGROUND AND PURPOSE: Cardiac troponins have shown to be specific markers of myocardial injury. The aim of this prospective study was to compare patterns and kinetics of troponin I and T after coronary artery bypass grafting (CABG) with or without perioperative myocardial infarction (PMI). PATIENTS AND METHODS: 119 patients (male/female: 96/23, age 64 +/- 10 years) underwent first time elective CABG. Preoperative mean ejection fraction was 55.8% +/- 15.6%. The mean number of grafts was 3.1 +/- 1.1/patient, in 85.7% the internal mammary artery was used. Cardiac troponin I (cTnI) and T (cTnT) levels, total serum activities of creatine kinase (CK) and creatine kinase isoenzyme MB (CK-MB) were measured before operation, at arrival on the intensive care unit (ICU), and 6, 12, 24, 48, and 120 h after unclamping of the aorta. Twelve lead electrocardiograms (ECGs) were recorded preoperatively and at days 1, 2, and 5. Perioperative data and postoperative cTnI and cTnT levels were correlated statistically. RESULTS: Two patients died due to refractory myocardial failure in the early postoperative period. For further evaluation, patients were divided in two groups according to postoperative ECG changes (group I: patients without PMI, n = 107; group II: patients with PMI, n = 10: six of them with Q-wave and four of them with non-Q-wave PMI). Calculated best cutoff values for cTnI and cTnT were 8.35 microg/l and 0.768 microg/l in ROC (receiver-operator characteristic) analysis. Serum concentrations of cTnI, and cTnT were in the normal range preoperatively and increased significantly after surgery in both groups. In both groups, cTnI reached its medium peak level after 24 h (group I: 2.7 microg/l, 95% confidence interval [CI]: [2.1,3.2]); group II: 70.5 microg/l). CTnT reached its medium peak level in group I without PMI after 48 h (0.298 microg/l, 95% CI: [0.254,0.354]), in group II with PMI not until 120 h (3.0 microg/l) postoperatively. In group II serum level of both troponins remained considerably high at 120 h (cTnI median = 10.75 microg/l, cTnT median = 3 microg/l). CONCLUSION: Release patterns of cTnI and cTnT after CABG are different: cTnI reaches its postoperative peak value earlier and declines more quickly than cTnT. After uncomplicated CABG, serum levels of both cardiac troponins remain continuously low. Elevated concentrations reflect perioperative myocardial ischemia or infarction. CTnT shows a different release pattern in patients with or without myocardial infarction.

Annexin V does not represent a diagnostic alternative to myoglobin for early detection of myocardial infarction.

Annexin V is a calcium binding protein, which is widely present in various cells and tissues. Due to an early release reaction after myocardial injury the determination of annexin V might be useful for the rapid diagnosis of acute myocardial infarction. An enzyme-linked immunosorbent assay was used to measure annexin V in comparison to myoglobin in samples from healthy individuals, patients suffering from acute or chronic liver, renal, and pulmonary diseases as well as acute coronary syndromes and aortocoronary bypass surgery. Increased myoglobin and annexin V concentrations were observed 80 and 140 (maximum) minutes after myocardial ischemia induced by percutaneous transluminal coronary angioplasty. For the diagnosis of myocardial infarction annexin V (cutoff-level: 5.9 microg/L) showed a slightly higher sensitivity than myoglobin (annexin V: 74.5%; myoglobin: 59.6%), but specificity was much lower (annexin V: 39%; myoglobin: 82.5%). The area under the curve of a ROC analysis demonstrated that annexin V cannot be used as an early marker for the diagnosis of acute coronary syndromes. Increased annexin V levels are induced by several diseases, leading to a low specificity for the diagnosis of a myocardial injury.