This study highlights the advantages of sutureless valves for geriatric patients with small aortic roots reflected by shorter cross-clamp and CPB times, even though most of these patients were operated on via a minimally invasive access. Moreover, due to the absence of a sewing ring, these valves are also almost stentless, with greater effective orifice area (EOA) for any given size. This may potentially result in better haemodynamics even without the root enlargement. This is of advantage, as several studies have shown that aortic root enlargement can significantly increase the risks of AVR. Moreover, as seen in this series, these valves may also enable a broader application of minimally invasive AVR.

A 55-year-old, previously healthy man was admitted to another hospital with deep-venous thrombosis in both legs and massive pulmonary embolism verified by chest computed tomography (CT). He presented with severe dyspnea and hypotension refractory to inotropes. Fibrinolytic therapy with recombinant tissue plasminogen activator was initiated, but the patient further deteriorated and required cardiopulmonary resuscitation for a period of 30 minutes. After return of spontaneous circulation, he remained in cardiogenic shock despite the use of inotropes and vasopressors, which is why our hospital was contacted.Our mobile extracorporeal membrane oxygenation (ECMO) team was dispatched and the patient received veno-arterial ECMO support with a 24 French venous cannula inserted via the right femoral vein and advanced into the right atrium and a 17 French arterial cannula inserted into the right femoral artery and advanced into the right iliacal artery. With an ECMO blood flow of 4.5 L/min, hemodynamics stabilized and the patient was transported to Hannover Medical School. Here, the patient was mechanically ventilated with an inspiratory oxygen fraction of 1.0 and the arterial PO 2 measured in blood obtained from the right radial artery was >400 mm Hg. The mean systemic blood pressure was 90 mm Hg, but the arterial pressure curves were almost nonpulsatile, and echocardiography showed little contractions of both the right and the left ventricle.Another CT scan performed approximately 14 hours after fibrinolysis showed persistent subtotal thromboembolic occlusion of the pulmonary vascular bed. In addition, there was an extensive filling defect in the ventral aspects of the ascending aorta (Figure 1). The left atrium, the left ventricle, and the aortic bulb were void of contrast material, whereas the aortic arch and the descending aorta were well contrasted (Figures 2 and 3).These images demonstrated the so-called ECMO watershed, where well-contrasted blood coming from the ECMO circuit met low-contrasted blood coming from the left ventricle. The patient with his subtotally occluded pulmonary vascular bed and near complete loss of cardiac contractility had almost complete blood supply from the ECMO and very little regular blood flow. The ECMO device took up most of the contrast media, whereas only a small amount passed the pulmonary vascular bed. Hence, the aorta was filled mostly retrograde. Most of the aorta, including all 3 supraaortic vessels, received well-contrasted and well-oxygenated blood from the ECMO whereas the aortic bulb with the coronary arteries received noncontrasted blood coming from the left ventricle (Figures 2 and 3).In patients receiving veno-arterial ECMO support, the term watershed describes the phenomenon that blood coming from the ECMO flows in the opposite direction than blood coming from the left ventricle.1,2 The level where these 2 blood streams meet (ie, the watershed) depends on the relative pressures and flows in both systems. The oxygen content of the blood coming from the left ventricle is un...

No abstract

Severe acute heart failure requires immediate intensive care unit (ICU) treatment, but prognosis and outcome of further treatment regimens largely depends on the preprocedural status of the patient. Especially, multiorgan failure including mechanical ventilation are unfavorable predictors of clinical outcome. Here, we report a strategy of immediate initiation of extracorporeal life support (ECLS) in awake and spontaneously breathing patients with acute heart failure to achieve early multiorgan recovery and gain sufficient time for further treatment planning. Twenty-three patients with severe cardiac failure refractory to standard medical management underwent ECLS treatment, after first clinical signs of cardiac failure appeared to avoid mechanical ventilation. Hemodynamic parameters and renal and liver functions were monitored. Outcome at 1 and 6 months was determined. Patients 46.1 ± 15.5 years of age were placed on ECLS due to various underlying diagnosis: ischemic heart disease (n = 6), dilatative cardiomyopathy (n = 4), myocarditis (n = 2), graft failure following heart transplantation (n = 6), or other diseases (n = 5). ECLS lasted 11.9 ± 12.9 days. Hemodynamic stabilization was achieved immediately after ECLS initiation. Vasopressors were reduced subsequently and the cardiac situation improved indicated by central venous saturation, which increased from 38.5 ± 11.3% before to 74.26 ± 8.4% (P < 0.0001) 24 h after ECLS initiation. Similarly, serum lactate levels decreased from 4.7 ± 4.6 to 1.7 ± 1.51 mmol/L (P = 0.003). Cumulative 30-day survival was 87.5%, and 6-month survival was 70.8%. In acute cardiac failure, early ECLS treatment is a safe, feasible treatment in awake patients allowing a gain of time for final decision. Moreover, this strategy avoids complications associated with sedation and mechanical ventilation and leads to recovery of secondary organ function, enabling destination therapy.

Nebacetin showed excellent in vitro antibacterial activity against both Gram-positive and -negative pathogens representing an effective candidate for vascular graft impregnation.