Neuroprotektion bei tiefem hypothermen Kreislaufstillstand am Schweinemodell

Zerebrale Schädigungen in Form persistierender fokaler Defizite und/oder temporärer neurologische Dysfunktionen (TND) stellen beim operativen Aortenbogenersatz infolge zerebraler Kurzzeitischämie ein bis heute nicht vollständig gelöstes klinisches Problem dar (Svensson et al. 1993, Ergin et al. 1994, Reich et al. 1999). Zwar konnte mit Einführung der Hypothermie und des hypothermen Kreislaufstillstandes (HCA) (Sealy et al. 1958, Barnard und Schrire 1963, Griepp et al. 1975) die Ischämietoleranz des Gehirns verlängert (Greeley et al. 1993, Griepp et al. 1997b) und das postoperative neurologische Ergebnis verbessert werden, dennoch bieten die angewandten neuroprotektiven Verfahren keinen sicheren zerebralen Schutz. Ziel der vorliegenden Arbeit war es, an einem chronischen Großtiermodell zu untersuchen, ob eine tiefe Hypothermie bei 10°C und/oder eine zusätzliche Behandlung mit Cyclosporin A (CsA) die zerebrale Schädigung nach hypothermem Kreislaufstillstand (HCA) weiter reduzieren kann

Modulation of Titin-Based Stiffness in Hypertrophic Cardiomyopathy via Protein Kinase D

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Mid-Term Outcomes after Transapical and Transfemoral Transcatheter Aortic Valve Implantation for Aortic Stenosis and Porcelain Aorta with a Systematic Review of Transfemoral versus Transapical Approach

Background We have aimed to analyze early and mid-term outcomes of patients undergoing transapical/transfemoral transcatheter aortic valve implantation (TA-/TF-TAVI) for aortic stenosis and porcelain aorta (PAo) in our institution. Additionally, we postulated that the TA approach may be associated with a more favorable neurological outcome than the TF approach; hence, a systematic literature review was conducted. Methods Between 2011 and 2017, 15 patients with PAo underwent TA-TAVI and 4 patients with PAo TF-TAVI at our institution. The assessment of PAo was done either intraoperatively after aborted sternotomy or via computed tomography for elective TAVI. We conducted mid-term follow-up. Furthermore, a systematic review was performed to compare the mortality and neurological outcomes of TF and TA-TAVI approaches. Results TA/TF-TAVIs were performed with 100% device success, without paravalvular leakage >= 2 and without procedural death. The 30-day mortality/stroke rates were 6.6%/0% in TA-TAVI and 0%/25% in TF-TAVI, respectively. The 6-month, 1-year, and 2-year survival rates were in TA/TF-TAVI 93%/75%, 82%/66.6%, and 50%/0%, respectively. The pooled results derived from the literature review were as follows: The prevalence of PAo in the TAVI population is 9.74%; the mean logistic EuroSCORE is 41.9% in TA-TAVI versus 16.2% in TF-TAVI; the mean 30-day mortality is 5.9% in TA-TAVI versus 6.3% in TF-TAVI, and the mean stroke is 0.8% in TA-TAVI versus 9% in TF-TAVI. Conclusion TA-TAVI shows promising early and mid-term outcomes in patients with PAo. TF-TAVI performed in patients with PAo is likely to be associated with higher rates of stroke than TA-TAVI

Transapical Valve Implantation After David Operation and Stenting of the Descending Aorta

This case report illustrates our experience with transapical minimally invasive aortic valve implantation in a patient with an extended aneurysm of the thoracoab-dominal aorta, who had previously undergone a replacement of the ascending aorta with concomitant aortic valve reconstruction (David procedure). Endovascular stent grafting of the descending aorta was also performed. The implantation of a 23-mm SAPIEN valve (Edwards Lifesciences, Irvine, CA) did not interfere with the existing 26-mm aortic Hemashield prosthesis (Boston Scientific, Natick, MA) or the previously implanted endograft in the descending aortic position. No paravalvular leakage with aortic valve regurgitation, prosthesis instability, or coronary malperfusion was seen after valve implementation. (Ann Thorac Surg 2010;90:2035-7) (C) 2010 by The Society of Thoracic Surgeon

Transcatheter Aortic Valve Implantation in Patients Who Cannot Undergo Transfemoral Access

Introduction Though transfemoral (TF) access has emerged as a gold standard access for patients with aortic stenosis who undergo transcatheter aortic valve implantation (TAVI), there has been no study that has characterized patients who cannot undergo TF access in detail. We aim to evaluate the contraindications for TF access, their incidence, classify them, and provide the outcomes of patients who failed to be TF candidates. Methods From 925 patients who underwent TAVI between February 2014 and May 2020 at our heart center, 130 patients failed to be TF candidates and underwent transapical-transcatheter aortic valve implantation (TA-TAVI). In this study, we included all those patients who failed to be TF candidates and underwent TA-TAVI using the third-generation balloon expandable valve (Edwards SAPIEN 3 valve [S3]) (116 patients; STS score 6.074.4; age 79.47). Results The incidence of patients unsuitable for TF access at our heart center was 14%. We classified this TAVI population into absolute contraindication for TF access n =84 (72.5%) and increased interventional risk for TF access n =32 (27.5%). After TA-TAVI of this specific population using S3, the in-hospital mortality and stroke were 1.7 and 1.7%, respectively. The vascular injury rate was 1.7%. We registered no paravalvular leakage >= 2. The pacemaker rate was 7.4%. The mean transvalvular pressure gradient was 8.7 mm Hg. Conclusion The incidence of patients who cannot undergo TF access or who are at high interventional risk is considerably high. TA-TAVI, supported with sufficient interventional experience and appropriate valve system, represents an excellent alternative for patients with distinct vasculopathy

Impact of Pump Flow Rate During Selective Cerebral Perfusion on Cerebral Hemodynamics and Metabolism

Background. Although hypothermic selective cerebral perfusion (SCP) is widely used for cerebral protection during aortic surgery, little is known about the ideal pump-flow management during this procedure. This study explored cerebral hemodynamics and metabolism at two different flow rates. Methods. Fourteen pigs (33 to 38 kg) were cooled on cardiopulmonary bypass to 25 degrees C. After 10 minutes of hypothermic circulatory arrest, the animals were randomly assigned to 60 minutes of SCP at two different pump flow rates: 8 mL . kg(-1) . min(-1) (n = 7) and 18 mL . kg(-1) . min(-1) (n = 7). Microspheres were injected at baseline, coolest temperature, and at 5, 15, 25, and 60 minutes of SCP to calculate cerebral blood flow, cerebral vascular resistance, metabolic rate, and intracranial pressure. Results. Cerebral blood flow decreased during cooling to 41% of the baseline value (from 57 +/- 10 to 23 +/- 4 mL . min(-1) . 100 g(-1)). It recovered during the initial 15 minutes of SCP, showing a significantly higher increase (p = 0.017) at high-flow versus low-flow perfusion (139 +/- 41 versus 75 +/- 22 mL . min(-1) . 100 g(-1)). After 60 minutes of SCP the cerebral blood flow almost returned to baseline values in the low-flow group (43 +/- 25 mL . min(-1) . 100 g(-1)), but showed an unexpected decrease (30 +/- 7 mL . min(-1) . 100 g(-1)) in the high-flow group. The highest regional cerebral blood flow was seen in the cortex (66 +/- 12 mL . min(-1) . 100 g(-1)), followed by the cerebellum (63 +/- 12 mL . min(-1) . 100 g(-1)), the pons (51 +/- 17 mL . min(-1) . 100 g(-1)), and the hippocampus (36 +/- 9 mL . min(-1) . 100 g(-1)). Intracranial pressure increased from 11 +/- 3 to 13 +/- 5 mm Hg during cooling on cardiopulmonary bypass. During low-flow SCP, it stayed stable at baseline values, whereas high-flow perfusion resulted in significantly higher intracranial pressures (17 +/- 3 mm Hg; p = 0.001). Changes in cerebral vascular resistance and metabolic rate showed no significant differences between the groups. Conclusions. High-flow SCP provides no benefit during long-term SCP at 25 degrees C. Higher cerebral blood flow during the initial SCP period leads to cerebral edema, with no profit in metabolic rate. (Ann Thorac Surg 2010;90:1975-84) (C) 2010 by The Society of Thoracic Surgeon

Oversized versus Non-oversized Prosthesis: Midterm Outcomes after Transcatheter Aortic Valve Replacement Using SAPIEN 3 Valve

Background A certain degree of prosthesis oversizing is recommended for the SAPIEN 3 (S3; Edwards Lifesciences Corp., Irvine, California, United States) to ensure device success. We aimed to investigate midterm outcomes in patients who received oversized (OS) S3 valve after transapical-transcatheter aortic valve replacement (TA-TAVR). Methods Out of 122 patients with aortic stenosis who underwent TA-TAVR using S3 at our institution, 42 received OS prosthesis. We used computed tomography (CT) derived effective diameter to assess oversizing. We defined oversizing if the labeled diameter of the selected valve for implantation was >= 2mm bigger than the effective annulus diameter calculated by the annulus area. We conducted a midterm follow-up and compared the OS cohort with the non-OS (nOS) cohort. Results The study groups showed similar risk score and age (STS [Society of Thoracic Surgery] score: 5.43; mean age: 80.7 +/- 5.7). The 30-day mortality was 7.1% in OS versus 2.4% in nOS. The 30-day all-stroke was 2.4% in OS versus 0% in nOS. The 1- and 3-year all-cause mortality were 28.5 and 42.8% in OS versus 21.9 and 26.8% in nOS, respectively. Midterm freedom from death and from cardiocerebral events was similar in both groups. Moderate/severe paravalvular leakage occurred in 0% in OS versus 5.4% in nOS. The postdilation rate was 7.1% in OS versus 15.3% in nOS. The rate of new permanent pacemaker implantation (PPI) was 15.7% in OS versus 9.3% in nOS. The STS score was detected as an independent predictor of mortality. Conclusion Oversizing reduces the risk of device failure and intraprocedural postdilation but increases the risk of PPI. Early and midterm morbidity and mortality after OS and nOS with S3 are comparable

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

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). 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. 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 degrees 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). 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

Transapical-transcatheter aortic valve implantation using the Edwards SAPIEN 3 valve

BACKGROUND: Scarcely any data has been published on the mid-term effect of transapical-transcatheter aortic valve implantation (TA-TAVI) using the Edwards SAPIEN 3 valve (S3; Edwards Lifesciences Corp., Irvine, CA, USA). We present mid-term clinical and echocardiographic outcomes after TA-TAVI utilizing S3. METHODS: Between 02/2014-06/2017, 122 elderly patients with severe aortic stenosis underwent TA-TAVI utilizing S3 at our institution. We conducted clinical and echocardiographic follow-up. The mean follow-up was 15 months. All end-point-related outcomes were adjudicated ac-cording to Valve Academic Research Consortium-2 definitions. RESULTS: The STS-score of the entire cohort was 6.26 +/- 4.6. More than one-third of the patients exhibited severe peripheral artery disease. The 30-d all-cause mortality, all-stroke rate, and myocardial infarction of the entire cohort were 4.1%, 1.6%, and 0.8% respectively. Median survival time of the entire cohort was 35 months. The cumulative mid-term myocardial infarction and stroke rate was 2.6% and 3.5%, respectively. The postoperative moderate/severe paravalvular leakage occurred in 1.6% of cases. At discharge, one-year and two-year postprocedure peak/mean gradients were 16.6 +/- 8.3/ 9 +/- 5.1 mmHg, 18 +/- 6.9/ 10 +/- 4.5 mmHg, and 22.2 +/- 5.4/ 12.8 +/- 4.6 mmHg, respectively. The rate of new pacemaker cases was 14.1%. Acute kidney injury network 2/3 appears, as an independent predictor of mortality. CONCLUSIONS: We observed very promising early and mid-term clinical outcomes with a high degree of device success and good hemody-namic performance after TA-TAVI using the S3 in the intermediate risk patient profile. (Cite this article as: Useini D, Schlomicher M, Beluli B, Christ H, Ewais E, Haldenwang P, et al. Transapical-transcatheter aortic valve implantation the Edwards SAPIEN 3 valve. J Cardiovasc DOI: 10.23736/S002

Transcatheter aortic valve replacement using the SAPIEN 3 valve versus surgical aortic valve replacement using the rapid deployment INTUITY valve: Midterm outcomes

Objectives Little data have been published on the midterm effect of transapical/transfemoral-transcatheter aortic valve replacement (TA-/TF-TAVR) using the Edwards SAPIEN 3 valve (S3). We aimed to compare the outcomes after TA-/TF-TAVR utilizing the S3 (TA-/TF-S3) valve with those after surgical aortic valve replacement utilizing the rapid deployment Edwards INTUITY valve (RD-SAVR). Methods Between March 2012 and April 2018, 122 patients with aortic stenosis underwent TA-S3, 77 patients underwent TF-S3 and 182 patients underwent RD-SAVR through partial sternotomy at our institution. We conducted clinical and echocardiographic midterm follow-ups. The primary outcomes of the study were the incidence of new pacemakers permanent pacemaker implantation (PPI), the occurrence of paravalvular leakage (PVL) and the hemodynamic performance of the valves. Results All study groups were at intermediate surgical risk. The 30-day all-cause mortality and stroke rates in the TA-S3, TF-S3, and RD-SAVR groups were 4.1% and 1.6%, 3.9% and 2.6%, and 3.8% and 2.2%, respectively. The RD-SAVR group had significantly smaller PVL and PPI rates than did the TA-/TF-S3 group (p < .0001). At the discharge, the one-year postprocedure mean gradients were 9 +/- 5.1/10 +/- 4.5 mmHg, 11 +/- 4.1/12 +/- 3.8 mmHg, and 10.1 +/- 4.3/10.4 +/- 2.6 mmHg in the TA-S3, TF-S3, and RD-SAVR groups, respectively. Midterm valve thrombosis, Re-TAVR/SVAR were low and similar among the study groups, whereas endocarditis was higher in the TAVR group. Conclusion RD-SAVR was superior to TA-/TF-S3 in the PVL and PPI rates. We observed similar early outcomes and valve hemodynamics. The endocarditis was higher in the TAVR group