Heart surgery and simultaneous carotid endarterectomy - 10-years single-center experience.

BACKGROUND: Patients with coronary artery heart disease frequently suffer concomitant carotid vascular disease and are at high perioperative risk for neurological adverse events. Several concepts regarding the timing and modality of carotid revascularization are controversially discussed in patients with heart disease. Current guidelines recommendations on myocardial revascularization recommend a concomitant carotid endarterectomy (CEA) in patients with a history of stroke/transient ischemic attack (TIA) or 50-99% grade of the carotid stenosis. Our study aimed to analyze early outcome parameters of patients undergoing coronary artery bypass grafting (CABG), but also including concomitant heart valve surgery and simultaneous CEA. METHODS: This study retrospectively analyzed a cohort of 111 patients from our institutional database undergoing heart surgery with CABG or heart-valve surgery between 2010 and 2020 with concomitant carotid surgery due to significant carotid stenosis. RESULTS: Patients undergoing heart and simultaneous carotid surgery were 77 ± 8.0 years of age with a body mass index of 28 ± 1.7 kg/m2 and a mean EuroSCORE II of 6.5 ± 2.3. Most patients (61%) had a smoking history and arterial hypertension (97%). The preoperative mean grade of internal carotid stenosis was 87 ± 4.2%, 13% of patients suffered from internal carotid artery stenosis on both sites. In total, 4.5% of patients had previously undergone internal carotid artery intervention before and 6.3% had a history of stroke with a persistent neurologic disorder in 1.8%, 8.9% of cases had prior TIA. Thirty-day all-cause mortality was 6.3% and postoperative neurologic events occurred with 7.2% TIA and 4.5% of disabling stroke. CONCLUSION: Within the reported patient population of coronary artery heart disease and significant internal carotid stenosis, a one-time approach with CABG or heart-valve surgery and CEA is safe and feasible as justified by clinical and neurological postoperative outcomes.

Impact of Lactate Clearance on Early Outcomes in Pediatric ECMO Patients.

Background and Objectives: Pediatric extracorporeal membrane oxygenation (ECMO) support is often the ultimate therapy for neonatal and pediatric patients with congenital heart defects after cardiac surgery. The impact of lactate clearance in pediatric patients during ECMO therapy on outcomes has been analyzed. Materials andMethods: We retrospectively analyzed data from 41 pediatric vaECMO patients between January 2006 and December 2016. Blood lactate and lactate clearance have been recorded prior to ECMO implantation and 3, 6, 9 and 12 h after ECMO start. Receiver operating characteristic (ROC) analysis was used to identify cut-off levels for lactate clearance. Results: Lactate levels prior to ECMO therapy (9.8 mmol/L vs. 13.5 mmol/L; p = 0.07) and peak lactate levels during ECMO support (10.4 mmol/L vs. 14.7 mmol/L; p = 0.07) were similar between survivors and nonsurvivors. Areas under the curve (AUC) of lactate clearance at 3, 9 h and 12 h after ECMO start were significantly predictive for mortality (p = 0.017, p = 0.049 and p = 0.006, respectively). Cut-off values of lactate clearance were 3.8%, 51% and 56%. Duration of ECMO support and respiratory ventilation was significantly longer in survivors than in nonsurvivors (p = 0.01 and p < 0.001, respectively). Conclusions: Dynamic recording of lactate clearance after ECMO start is a valuable tool to assess outcomes and effectiveness of ECMO application. Poor lactate clearance during ECMO therapy in pediatric patients is a significant marker for higher mortality.

Management of out-of hospital cardiac arrest patients with extracorporeal cardiopulmonary resuscitation in 2021.

INTRODUCTION: Over the last decade, eCPR programs have become more and more popular, at least amongst high-volume centers. Despite its rise in popularity and promising outcome, strategies concerning pre- and post-implantation of VA-ECMO remain at least debatable. Besides, integrating the appropriate set-up, managing anticoagulation, implementing LV-venting, and predicting neurological outcome play important roles in caring for thise highly selective patient-collective. We sought to present our institutional´s techniques for establishing an eCPR program and managing patients peri- and post implantation in eCPR-runs. AREAS COVERED: This manuscript covers the majority of clinical concerns and parameters for establishing an eCPR program and its recent advantages. We will describe a safe way of cannulation, setting anticoagulation goals, strategies for LV-venting and ICU-treatment. Also included, an elaboration on neurological and cardiac prognostication. EXPERT OPINION: We advocate ultrasound-guided cannula placement in eCPR patients. Also, we emphasize the importance of using stiffer wires and smaller arterial cannula sizes due to the different physiological parameters of OHCA patients. After cannulation, we aim for lower flow goals, the concept of 'partial VA-ECMO,' and lower anticoagulatory targets. LV-venting with Impella should remain an individual case to case decision.

Early and long-term outcomes comparing neonates, infants, and preadolescents requiring extracorporeal membrane oxygenation for heart failure.

BACKGROUND: Application of extracorporeal membrane oxygenation in pediatric patients with severe heart failure steadily increases. Differentiation of outcomes and survival of diverse pediatric groups is of interest for adequate therapy. METHODS: Between January 2008 and December 2016, a total of 39 pediatric patients needed veno-arterial extracorporeal membrane oxygenation support in our department. Patients were retrospectively divided into three groups: neonates (<30 days), infants (>30 days/<1 year), and toddlers/preadolescents (>1 year). Early outcomes as well as mid- and long-term survival up to 7-year follow-up were analyzed. RESULTS: Basic demographics significantly differed in terms of age, height, and weight among the groups in accordance with the intended group categorization (p < 0.05). Survival after 30 days of extracorporeal membrane oxygenation application was equally distributed among the groups, and 44% of all patients survived. In terms of survival to discharge, no significant differences were found among groups. In total, 28% of patients survived up to 7 years. Infants were significantly more likely to undergo elective surgery (p < 0.001) and were predominantly weaned off extracorporeal membrane oxygenation, whereas need for urgent surgery (p < 0.001) was significantly higher in neonate group in comparison to other groups. Multinominal logistic regression analysis revealed significantly higher odds for need for re-exposure in infant group in comparison to toddler/preadolescent group as well as for incidence of neurological impairment of toddler/preadolescent group in comparison to neonate group (odds ratio = 14.67, p = 0.009 and odds ratio = 34.67, p = 0.004, respectively). Kaplan-Meier survival estimation analysis revealed no significant differences in terms of mid- and long-term survival among the groups (Breslow p = 0.198 and log-rank p = 0.213, respectively). CONCLUSION: Veno-arterial extracorporeal membrane oxygenation is a lifesaving therapeutic chance for pediatric patients in the setting of either failure to wean from cardiopulmonary bypass or failed resuscitation from cardiac arrest. A fair part of patients could be saved by using this technology. Survival rate among the groups was similar.

Pediatric patients requiring extracorporeal membrane oxygenation in heart failure: 30-day outcomes; mid- and long-term survival. A single center experience.

Nowadays, an increasing number of neonatal and pediatric patients with severe heart failure benefits from extracorporeal membrane oxygenation (ECMO) support. A total of 39 pediatric patients needed venoarterial ECMO (vaECMO) support in our department between January 2008 and December 2016. Patients were retrospectively divided in two groups: 30-day survivor group (17 patients) and 30-day nonsurvivor group (22 patients). Outcome and factors predictive for 30-day mortality and mid- as well as long-term survival up to 7-year follow-up were analyzed by univariate analysis and Kaplan-Meier survival estimation. Basic demographics and preoperative characteristics did not differ between groups (P > 0.05). 67% of patients were successfully weaned off ECMO and 44% survived 30-day after ECMO application. After 7-year follow-up 28% of pediatric patients were alive. Thirty-day survivors were significantly more likely to undergo elective cardiac surgery (P = 0.001), whereas significantly more 30-day nonsurvivors underwent urgent surgery (P = 0.004). Odds of incidence of catecholamine refractory circulatory failure, failed myocardial recovery, and cerebral edema was significantly higher in 30-day nonsurvivor group (41.6-fold, 16-fold, and 2.5-fold, respectively). Kaplan-Meier survival estimation analysis revealed significant differences in terms of mid- and long-term survival among neonates, infants, toddlers, and preadolescents (Breslow P = 0.037 and Log-Rank P = 0.028, respectively). vaECMO provides an efficient therapy option for life-threatening heart disorders in neonates and pediatric patients being at high risk for myocardial failure leading to circulatory arrest. Urgency of surgery effected on higher mortality, but there was no difference in terms of mortality in 30-day survivor group in comparison to 30-day nonsurvivor group among neonates, infants, toddlers, and preadolescents.

Angiosarcoma of the Left Atrium: A Case Report.

Background Primary cardiac tumors are rare, and many diagnosed tumors are benign with an incidence of 0.001% to 0.03%. The primary angiosarcoma is one of the malignant entities. Discussion We discuss a case report of a 76-year-old male who underwent a preoperative diagnosis for an upcoming shoulder operation when his cardiologist diagnosed a large cardiac tumor. The patient was referred to our department where he received further diagnostics. The transesophageal echocardiography and the cardiac-magnetic resonance imaging showed a massive tumor with a dimension of 8.6 × 5.6 cm with no signs of malignity. Method The operation was performed by standard median sternotomy. The tumor was adherent to the septum and the left atrium, and we were able to remove the specimen in toto. Pathological examinations showed an angiosarcoma with neovascularization and core expression of ERG+ and cytoplasmic expression of CD31+/CD34+, due to the size of the mass. The resection of primary cardiac tumors is mostly the therapy of choice, but in this case concerning an angiosarcoma the prognosis is poor, considering that the angiosarcoma responds very badly to chemotherapy and radiotherapy.

Six-years survival and predictors of mortality after CABG using cold vs. warm blood cardioplegia in elective and emergent settings.

BACKGROUND: The aim of this study was to determine whether intermittent warm blood cardioplegia (IWC) is associated with comparable myocardial protection compared to cold blood cardioplegia (ICC) in patients undergoing elective vs. emergent CABG procedures. METHODS: Out of 2292 consecutive patients who underwent isolated on-pump CABG surgery using cardioplegic arrest either with ICC or IWC between January 2008 and December 2010, 247 consecutive emergent patients were identified and consecutively matched 1:2 with elective patients based on gender, age (<50 years, 50-70 years, >70 years) and ejection fraction (<40 %, 40-50 %, >50 %). Perioperative outcomes and long-term mortality were compared between ICC and IWC strategies and predictors for 30-day mortality and perioperative myocardial injury were identified in both elective and emergent subgroups of patients. RESULTS: Preoperative demographics and baseline characteristics, logistic Euroscore, CPB-time, number of distal anastomoses and LIMA-use were comparable. Aortic cross clamp time was significantly longer in the IWC-group regardless of the urgency of the procedure (p = 0.05 and p = 0.015 for emergent and elective settings). There were no significant differences regarding ICU-stay, ventilation time, total blood loss and need for dialysis. The overall 30-day, 1-, 3- and 6-year survival of the entire patient cohort was 93.7, 91.8, 90.4 and 89.1 %, respectively, with significantly better outcomes when operated electively (p < 0.001) but no differences between ICC and IWC both in elective (p = 0.857) and emergent (p = 0.741) subgroups. Multivariate analysis did not identify the type of cardioplegia as a predictor for 30-day mortality and for perioperative myocardial injury. However, independent factors predictive of 30-day mortality were: EF < 40 % (OR 3.66; 95 % CI: 1.79-7.52; p < 0.001), atrial fibrillation (OR 3.33; 95 % CI: 1.49-7.47; p < 0.003), peripheral artery disease (OR 2.51; 95 % CI: 1.13-5.55; p < 0.023) and COPD (OR 0.26; 95 % CI: 1.05-6.21; p < 0.038); predictors for perioperative myocardial infarction were EF < 40 % (OR 2.04; 95 % CI: 1.32-3.15; p < 0.001), preoperative IABP support (OR 3.68; 95 % CI: 1.34-10.13; p < 0.012), and hemofiltration (OR 3.61; 95 % CI: 2.22-5.87; p < 0.001). CONCLUSION: Although the aortic cross clamp time was prolonged in the IWC group our results confirm effective myocardial protection under IWC, regardless of the urgency of the procedure. We suggest that intermittent warm cardioplegia in emergent CABG setting is a low-cost alternative and safe. It is associated with similar long-term outcomes both in elective and emergent settings compared to intermittent cold cardioplegia.

Impact of major non-cardiac complications on outcome following cardiac surgery procedures: logistic regression analysis in a very recent patient cohort.

OBJECTIVES: In this study, we sought to analyse the incidence of major non-cardiac complications and their impact on survival following cardiac surgery procedures in a contemporary patient cohort. We further determined independent predictors of perioperative mortality and created a logistic regression model for prediction of outcome after the occurrence of these complications. METHODS: Prospectively collected data of 5318 consecutive adult patients (mean age 68.9±11.0 years; 29.3% [n=1559] female) undergoing cardiac surgery from January 2009 to May 2012 were retrospectively analysed. Outcome measures were six major non-cardiac complications including respiratory failure, dialysis-dependent renal failure, deep sternal wound infection (DSWI), cerebrovascular accident (CVA), gastrointestinal complications (GIC) and sepsis and their impact on perioperative mortality and hospital length of stay using multivariate regression models. The discriminatory power was evaluated by calculating the area under the receiver operating characteristic curves (C statistic). RESULTS: A total of 1321 complications were observed in 846 (15.9%) patients: respiratory failure (n=432; 8.1%), dialysis-dependent renal failure (n=295; 5.5%), GIC (n=154; 2.9%), CVA (n=151; 2.8%), DSWI (n=146; 2.7%) and sepsis (n=143; 2.7%). Perioperative mortality was 17.0% in patients with at least one major non-cardiac complication and correlated with the number of complications (single, 9.7%; n=53/549; double, 24.0%; n=44/183; ≥3, 41.2%; n=47/114, P<0.001). Six preoperative and four postoperative independent predictors of operative mortality were identified (age (odds ratio [OR] 1.8; 95% confidence interval [CI] 1.3-2.4), peripheral vascular disease (OR 2.6; 95% CI 1.6-4.2), pulmonary hypertension (OR 2.7; 95% CI 1.5-4.9), atrial fibrillation (OR 1.5; 95% CI 1.0-2.3), emergency (OR 5.0; 95% CI 3.4-7.2), other procedures than CABG (OR 1.5; 95% CI 1.0-2.1), postoperative dialysis (OR 4.0; 95% CI 2.6-6.1), sepsis (OR 3.4; 95% CI 2.0-5.6), respiratory failure (OR 3.2; 95% CI 2.2-4.9), GIC (OR 3.2; 95% CI 1.9-5.3)) and included in the logistic model, which accurately predicted outcome (C statistic, 0.892; 95% CI 0.868-0.916). Length of hospital stay was significantly increased according to the number of complications (single: median 15 (IQR 10-24) days, double: 16 (IQR 8-28) days, ≥3: 20 (IQR 13-39) days, P<0.001). CONCLUSIONS: With a worsening in the risk profile of patients undergoing cardiac surgery, an increasing number of patients develop major complications leading to increased length of stay and mortality, which is correlated to the number and severity of these complications. Our predictive model based on preoperative and postoperative variables allowed us to determine with accuracy the perioperative mortality in critically ill patients after cardiac surgery.

Recurrent left atrial and left ventricular thrombosis due to heparin-induced thrombocytopenia: case report and short review.

The combination of heparin-induced thrombocytopenia (HIT) II, left ventricular failure with extracorporeal membrane oxygenation (ECMO) therapy, and recurrent left ventricular thrombosis is rare and predicts a poor outcome. In this case, HIT II occurred after an ischemic cardiogenic shock. We initiated ECMO and intra-aortic balloon pump therapy during coronary artery bypass grafting and ventricular thrombectomy. Despite continued therapeutic therapy with heparin and later argatroban, the patient developed solid and recurrent thrombotic masses in the left atrium and left ventricle.

Evaluation of risk factors for transient neurological dysfunction and adverse outcome after repair of acute type A aortic dissection in 122 consecutive patients.

OBJECTIVES: The aim of this retrospective study was to assess pre- and intraoperative factors leading to neurological complications and early death following repair of acute type A aortic dissection (ATAAD). METHODS: There were 122 patients (85 male, age: 58.6 ± 12.5 years) with ATAAD, treated consecutively from August 2003 to August 2010. Pre- and intraoperative variables were analysed using a logistic regression model in order to identify risk factors for temporary neurological dysfunction (TND) and adverse outcome (AO), defined as stroke and 30-day mortality. RESULTS: The 30-day mortality rate was 16.4%. Forty-one patients (33.6%) suffered transient neurological dysfunction and 20 (16.4%) had a postoperative stroke. Mean hypothermic circulatory arrest (HCA) temperature was 24 ± 4 °C. Selective cerebral perfusion (SCP) was performed in 99 (82%) patients, with a mean SCP flow rate of 10.3 ml/kg/min. The duration of lower body ischaemia (LBI) was 36 ± 27 min, of HCA 8.7 ± 15.5 min and of SCP 34 ± 28 min, respectively. Male gender [odds ratio (OR): 3.30, 95% confidence interval (CI): 1.15-9.47], diabetes (OR: 3.95, 95% CI: 1.18-13.24), compromised consciousness (OR: 6.65, 95% CI: 1.41-31.48) and manifest arterial atherosclerosis (OR: 6.68, 95% CI: 1.31-34.09) were detected as risk factors for TND, whereas a high body mass index (OR: 1.14, 95% CI: 1.01-1.3), a preoperative malperfusion syndrome (OR: 2.28, 95% CI: 0.84-6.18) and left ventricular ejection fraction <50% (OR: 3.84, 95% CI: 1.41-10.43) were detected as independent predictors for an AO. A dissection entry localized in the aortic arch or the descending aorta independently increased the risk for a postoperative stroke. A prolonged LBI increased the risk for AO (OR: 1.02, 95% CI: 1.00-1.04), whereas femoral cannulation showed a trend to an increased stroke incidence (OR: 4.2, 95% CI: 0.8-21.3). CONCLUSIONS: Regardless of standardized neuroprotective techniques, treatment of ATAAD remains a high-risk operation. Preoperatively, the presence of a reduced ejection fraction, a malperfusion syndrome or a high body mass index may increase the perioperative risk for an adverse outcome. A dissection 'entry' localized in the aortic arch or the descending aorta may increase the risk for postoperative stroke. Intraoperatively, cannulation of the femoral artery and extension of the LBI time over 45 min should be avoided. Especially in patients with manifest preoperative cerebral and/or end-organ malperfusion, the cannulation modality as well as the entire neuroprotective management should be chosen individually, respecting its limitations.