[ESC/EACTS guidelines on myocardial revascularization 2018 : The most important innovations]. / ESC/EACTS-Leitlinien zur Myokardrevaskularisation 2018 : Die wichtigsten Neuerungen.

The guidelines on myocardial revascularization published in 2018 are a joint initiative of the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery. To establish indications for myocardial revascularization by percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), evidence of the functional relevance of coronary artery stenoses is needed either by non-invasive imaging function tests or intravascular hemodynamic measurements. The prognostic and symptomatic benefits of myocardial revascularization depend on whether complete revascularization can be achieved. This needs to be considered when choosing the most appropriate revascularization strategy. In addition, the individual operative risk, the technical feasibility, the presence of diabetes mellitus and the anatomical complexity of coronary artery disease, as assessed by the SYNTAX score, are key criteria when choosing the optimal method of revascularization. For PCI radial artery access and the general use of drug-eluting stents are recommended. For CABG multiple arterial grafts should be strived for including the radial artery for treatment of high-grade coronary stenosis.

A Rare Case of Diffuse Hemangiomatosis of the Spleen with Splenic Rupture following Aortic Valve Replacement.

In this paper we present a rare case of splenic rupture that occurred after an open aortic valve replacement in a male patient with hemangiomatosis of the spleen and the liver. The patient was treated with an emergency splenectomy. He showed no other sings of associated systemic disorder, such as Klippel-trénaunay syndrome or Proteus syndrome.

Cardiac thrombus with risk of fulminant pulmonary embolism in paediatric antiphospholipid syndrome.

Antiphospholipid Syndrome (APS) describes a systemic disease caused by autoantibodies to membrane components. Involving coagulation pathways, complement factors and immune cells, it results in thrombosis in any blood vessel. Its clinical presentation varies considerably depending upon the organ affected. Paediatric data on APS remain sparse. Most case reports focus on catastrophic APS with multiple small-vessel occlusions and a life-threatening course. Here, we report on a 15-year-old patient with deep vein thrombosis and a right ventricular tumour posing the risk of a fulminant pulmonary embolism. The tumour was surgically removed. Histology revealed it to be a thrombus. The patient fully recovered and is currently treated with long term anticoagulation.

Bronchial compression following pulmonary artery stenting in single ventricle lesions: how to prevent, and how to decompress.

OBJECTIVES: To assess airway compression during pulmonary artery (PA) intervention in single ventricle (SV) palliation. BACKGROUND: SV lesions with a prominent neo-aortic root are considered a high risk for branch PA and/or bronchial stenosis. PA stenting is well established, but may result in ipsilateral bronchial compression. METHODS: Single-centre retrospective analysis of 19 palliated SV patients with branch PA stenosis and close proximity to the ipsilateral main bronchus who underwent cardiac catheterisation at a median age and weight of 8.5 years (0.5-25) and 16.5 kg (6-82) between 12/2011 and 05/2015. RESULTS: Two of the 19 patients suffered an almost-closed left-main bronchus (LMB) following PA stenting. Fortunately, LMB decompression succeeded in both those patients by re-shaping the PA stents by compressing the chest while splinting the LMB with an inflated balloon. To prevent the other 17 patients from suffering this serious complication, we adopted a thorough preparation strategy: 13 patients underwent safe simultaneous bronchoscopy and cardiac catheterisation; in the remaining 4 patients CT-angiography enabled accurate risk evaluation prior to re-catheterisation. CONCLUSIONS: In SV lesions accompanied by branch PA stenosis, thorough preparation via cross-sectional imaging is mandatory, including simultaneous bronchoscopy and cardiac catheterisation in selected cases, to rule out any airway compression before considering endovascular stent implantation. If a PA stent's compression has already caused severe bronchial obstruction, our balloon-splinted decompression technique should be considered.

Pathophysiological implications of different bicuspid aortic valve configurations.

There are numerous types of bicuspid aortic valve (BAV) configurations. Recent findings suggest that various BAV types represent different pathophysiological substrates on the aortic media level. Data imply that the BAV type is probably not related to location and extent of the aneurysm. However, BAV type is likely linked to the severity of aortic media disease. Some BAVs with raphe seem more aggressive than BAV without a raphe. Cusp fusion pattern, altered hemodynamics, and the qualitative severity of the disease in the aortic media might on the one hand share the same substrate. On the other hand, the aortopathy's longitudinal extent and location may represent a different pathophysiological substrate, probably dictated by the heritable aspects of BAV disease. The exact nature of the relation between BAV type and the aneurysm's location and extent as well as to the risk of aortic complications remains unclear. This paper reviews results of recent human and experimental studies on the significance of BAV types for local aortic media disease and location and extent of the aortopathy. We describe the known and hypothesized hemodynamic and hereditary factors that may result in aortic aneurysm formation in BAV patients.

[CT Angiography for the pre- and postoperative evaluation of the thoracic aorta]. / CT-Angiografie zur prä- und postoperativen Evaluation in der thorakalen Aortenchirurgie.

CT angiography is the imaging modality of choice for the pre- and postsurgical evaluation of patients with pathologies of the thoracic aorta. The purpose of this review is to familiarize the reader with the technical principle, recent technical developments and requirements for specific examination protocols and image interpretation, and to highlight common pathologies and findings.

The management of acute limb ischemia.

Acute limb ischemia (ALI) is one of the most common vascular emergencies and characterized by sudden worsening of limb perfusion mainly caused by embolization of thrombotic masses or acute graft occlusion. It is a serious condition with potential thread to limb viability accompanied by significant mortality, morbidity and costs. This article provides an overview of etiology, classification and treatment options of ALI ischemia with special focus on the issue of postreperfusion syndrome. The concept of reperfusion injury following limb ischemia and a system for controlled limb reperfusion to offset postreperfusion synsrome is described in detail.

Clinical experience with the VentrAssist left ventricular assist device.

INTRODUCTION: Left ventricular mechanical assist device (LVAD) support is well established as a bridge to transplantation and as an alternative to transplantation in patients with end-stage heart failure. There are currently various LVAD systems available based on different types of pump technology. We present the VentrAssist LVAD, a centrifugal pump, and focus on a surgical implantation technique that may help reduce the complications typically associated with VAD surgery. METHODS AND RESULTS: 412 patients underwent VentrAssist LVAD implantation between June 2003 and January 2009 worldwide. The overall rate of success was 81 % (i.e., ongoing, HTX, or recovery). Interestingly hemolysis is greatly reduced with this intracorporeal centrifugal LVAD compared to other VAD systems with other pump designs. Our surgical implantation technique and strategy may contribute to reducing complications. CONCLUSION: The VentrAssist is a powerful and effective LVAD; its use can considerably reduce hemolysis. Long-term follow-up is necessary to determine whether the VentrAssist is appropriate as a bridge to transplant as well as feasible for long-term application.

Protective effects of inhaled carbon monoxide in pig lungs during cardiopulmonary bypass are mediated via an induction of the heat shock response.

BACKGROUND: Cardiopulmonary bypass (CPB) may cause acute lung injury leading to increased morbidity and mortality after cardiac surgery. Preconditioning by inhaled carbon monoxide reduces pulmonary inflammation during CPB. We hypothesized that inhaled carbon monoxide mediates its anti-inflammatory and cytoprotective effects during CPB via induction of pulmonary heat shock proteins (Hsps). METHODS: Pigs were randomized either to a control group, to standard CPB, to carbon monoxide+CPB, or to quercetin (a flavonoid and unspecific inhibitor of the heat shock response)+control, to quercetin+CPB, and to quercetin+carbon monoxide+CPB. In the carbon monoxide groups, lungs were ventilated with 250 ppm carbon monoxide in addition to standard ventilation before CPB. At various time points, lung biopsies were obtained and pulmonary Hsp and cytokine concentrations determined. RESULTS: Haemodynamic parameters were largely unaffected by CPB, carbon monoxide inhalation, or administration of quercetin. Compared with standard CPB, carbon monoxide inhalation significantly increased the pulmonary expression of the Hsps 70 [27 (SD 3) vs 69 (10) ng ml(-1) at 120 min post-CPB, P<0.05] and 90 [0.3 (0.03) vs 0.52 (0.05) after 120 min CPB, P<0.05], induced the DNA binding of heat shock factor-1, reduced interleukin-6 protein expression [936 (75) vs 320 (138) at 120 min post-CPB, P<0.001], and decreased CPB-associated lung injury (assessed by lung biopsy). These carbon monoxide-mediated effects were inhibited by quercetin. CONCLUSIONS: As quercetin, a Hsp inhibitor, reversed carbon monoxide-mediated pulmonary effects, we conclude that the anti-inflammatory and protective effects of preconditioning by inhaled carbon monoxide during CPB in pigs are mediated by an activation of the heat shock response.