Background: Cardiac surgery often represents the only treatment option in patients with infective endocarditis (IE). However, IE surgery may lead to a sudden release of inflammatory mediators, which is associated with the severity of postoperative organ dysfunction. We investigated the impact of hemoadsorption during IE surgery on postoperative organ dysfunction. Methods: This multi-center, randomized, non-blinded, controlled trial assigned patients undergoing cardiac surgery for IE to hemoadsorption [integration of CytoSorb® to cardiopulmonary bypass (CPB)] or control. The Primary outcome (ΔSOFA) was defined as the difference between the mean total postoperative sequential organ failure assessment score (SOFA), calculated maximally to the 9th postoperative day, and the basal SOFA score. The analysis was by modified intention-to-treat. A predefined inter-group comparison was done using a linear mixed model for ΔSOFA including surgeon and baseline SOFA as fixed effect covariates and with the surgical center as random effect. The SOFA score assesses dysfunction in six organ systems, each scored from zero to four. Higher scores indicate worsening dysfunction. Secondary outcomes were 30-day mortality, durations of mechanical ventilation, vasopressor and renal replacement therapy. Cytokines were measured in the first 50 patients. Results: Between January 17, 2018 and January 31, 2020, A total of 288 patients were randomly assigned to hemoadsorption (n=142) or control (n=146). Four patients in the hemoadsorption and two in the control group were excluded as they did not undergo surgery. The primary outcome ΔSOFA did not differ between the hemoadsorption and the control group (1.79 ± 3.75 and 1.93 ± 3.53, respectively, 95% CI: −1.30 to 0.83, p=0.6766). Mortality at 30 days (21% hemoadsorption vs 22% control, p=0.782), the durations of mechanical ventilation, vasopressor and renal replacement therapy did not differ between groups. Levels of IL-1β and IL-18 at the end of CPB were significantly lower in the hemoadsorption than in the control group. Conclusions: This randomized trial failed to demonstrate a reduction in postoperative organ dysfunction through intraoperative hemoadsorption in patients undergoing cardiac surgery for IE. Although hemoadsorption reduced plasma cytokines at the end of CPB, there was no difference in any of the clinically relevant outcome points.

Background Delirium is a common complication after cardiac surgery that leads to increased costs and worse outcomes. This retrospective study evaluated the potential risk factors and postoperative impact of delirium on cardiac surgery patients. Methods One thousand two hundred six patients who underwent open-heart surgery within a single year were included. Uni- and multivariate analyses of a variety of pre, intra-, and postoperative parameters were performed according to differences between the delirium (D) and nondelirium (ND) groups. Results The incidence of delirium was 11.6% (n = 140). The onset of delirium occurred at 3.35 ± 4.05 postoperative days with a duration of 5.97 ± 5.36 days. There were two important risk factors for postoperative delirium: higher age (D vs. ND, 73.1 ± 9.04 years vs. 69.0 ± 11.1 years, p < 0.001) and longer aortic cross-clamp time (D vs. ND, 69.8 ± 49.9 minutes vs. 61.6 ± 53.8 minutes, p < 0.05). We found that delirious patients developed significantly more frequent postoperative complications, such as myocardial infarction (MI) (D vs. ND, 1.43% [n = 3] vs. 0.28% [n = 2], p = 0.05), cerebrovascular accident (D vs. ND, 10.7% [n = 15] vs. 3.75% [n = 40], p < 0.001), respiratory complications (D vs. ND, 16.4% [n = 23] vs. 5.72% [n = 61], p < 0.001), and infections (D vs. ND, 36.4% [n = 51] vs. 16.0% [n = 170], p < 0.001). The hospital stay was longer in cases of postoperative delirium (D vs. ND, 23.2 ± 13.6 days vs. 17.4 ± 12.8 days, p < 0.001), and fewer patients were discharged home (D vs. ND, 56.0% [n = 65] vs. 66.8% [n = 571], p < 0.001). Conclusions Because the propensity for delirium-related complications is high after cardiac surgery, a practical, preventative strategy should be developed for patients with perioperative risk factors, including higher age and a longer cross-clamp time.

Low immunogenicity and high repopulation capacity are crucial determinants for the functional and structural performance of acellular cardiovascular implants. The present study evaluates a detergent-free, non-proteolytic, actin-disassembling regimen (BIO) for decellularization of heart valve and vessel grafts, particularly focusing on their bio-functionality. Rat aortic conduits (rAoC; n = 89) and porcine aortic valve samples (n = 106) are decellularized using detergents (group DET) or the BIO regimen. BIO decellularization results in effective elimination of cellular proteins and significantly improves removal of DNA as compared with group DET, while the extracellular matrix (ECM) structure as well as mechanical properties are preserved. The architecture of rAoC in group BIO allows for improved bio-functionalization with fibronectin (FN) in a standardized rat implantation model: BIO treatment significantly increases speed and amount of autologous medial cellular repopulation in vivo (p < 0.001) and decreases the formation of hyperplastic intima (p < 0.001) as compared with FN-coated DET-decellularized grafts. Moreover, there are no signs of infiltration with inflammatory cells. The present biological, detergent-free, non-proteolytic regimen balances effective decellularization and ECM preservation in cardiovascular grafts, and provides optimized bio-functionality. Additionally, this study implies that the actin-disassembling regimen may be a promising approach for bioengineering of acellular scaffolds from other muscular tissues, as for example myocardium or intestine. Copyright © 2017 John Wiley & Sons, Ltd.

OBJECTIVES Mitral valve repair is the preferred method used to address mitral valve regurgitation, whereas transcatheter mitral valve repair is recommended for high-risk patients. We evaluated the risk-predictive value of the age-adjusted Charlson comorbidity index (aa-CCI) in the setting of minimally invasive mitral valve surgery. METHODS The perioperative course and 1-year follow-up of 537 patients who underwent isolated or combined minimally invasive mitral valve surgery were evaluated for 1-year mortality as the primary end point and other adverse events. The predictive values of the EuroSCORE II and STS score were compared to that of the aa-CCI by a comparative analysis of receiver operating characteristic curves. Restricted cubic splines were applied to find optimal aa-CCI cut-off values for the increased likelihood of experiencing the predefined adverse end points. Consequently, the perioperative course and postoperative outcome of the aa-CCI ≥8 patients and the remainder of the sample were analysed. RESULTS The predictive value of the aa-CCI does not significantly differ from those of the EuroSCORE II or STS score. Patients with an aa-CCI ≥8 were identified as a subgroup with a significant increase of mortality and other adverse events. CONCLUSIONS The aa-CCI displays a suitable predictive ability for patients undergoing minimally invasive mitral valve surgery. In particular, multimorbid or frail patients may benefit from the extension of the objectively assessed parameters, in addition to the STS score or EuroSCORE II. Patients with an aa-CCI ≥8 have a very high surgical risk and should receive very careful attention.

Despite the critical feature of heparin-induced thrombocytopenia (HIT) for patients on mechanical circulatory support, reports on its incidence and outcome are still scarce. Thus, we report on clinical features of HIT in patients under Impella 5.0 or 5.5 (Abiomed Inc., Danvers, MA, USA) (Impella 5+) support for acute cardiogenic shock (CS) by focusing on observed thrombotic events. Between November 2018 and December 2020, a total of 56 consecutive patients were enrolled in a single-center retrospective study. A total of 21 patients (37.5%) were tested for HIT, and 6 (10.7%) proved positive for HIT at 10.5 ± 2.89 days after the first heparin administration during current admission. Interestingly, thrombocyte counts dropped under Impella support in all groups (all cases, no HIT test, and HIT negative group: p < 0.001, HIT-positive group: p = 0.001). All HIT-positive patients were switched from heparin to argatroban. HIT-associated thrombotic events were observed in two cases resulting in Impella dysfunction due to pump thrombosis (n = 1) and left ventricular (LV) thrombus formation (n = 1). Under large Impella support, the prevalence of HIT was relatively high. Further, thrombocytopenia does not deliver a high specificity in the setting of Impella 5+ support. Considering HIT manifestation, a routine HIT test may be considered to avoid critical thrombotic adverse events.

Open heart surgery in patients with liver cirrhosis is considered to be very risky, but the predictors of poor outcomes in such cases have not been established. We report the perioperative results of open heart surgery in patients with liver cirrhosis in our hospital. We reviewed the results of 13 cases in 12 patients with liver cirrhosis who underwent open heart surgery between January 2001 and December 2010. The Child-Turcotte-Pugh classification, the model for end-stage liver disease score, EuroSCORE, and perioperative data were used to identify risk factors for morbidity and mortality retrospectively. Ten patients had postoperative complications. Significant differences in morbidity were evident for Child-Turcotte-Pugh class, cardiopulmonary bypass time, and crossclamp time. Two patients died of liver failure, one at 40 days and the other at 2 years after surgery. Statistically significant differences in liver-related mortality were evident in the model for end-stage liver disease scores and serum cholinesterase levels. We concluded that a high Child-Turcotte-Pugh class was associated with increased morbidity. Cardiopulmonary bypass and crossclamp times were also related to high morbidity, while high model for end-stage liver disease scores and low serum cholinesterase levels predicted liver-related mortality.

Aims Pre‐operative or post‐operative heart failure (HF) and cardiogenic shock of various natures frequently remain refractory to conservative treatment and require mechanical circulatory support. We report our clinical experience with large Impella systems (5.0 or 5.5; i.e. Impella 5+) (Abiomed Inc., Boston, USA) and evaluate the parameters that determined patient outcome. Methods and results The initial 50 cases of Impella 5+ implanted for acute HF between November 2018 and August 2020 at a single centre were enrolled in this study. Data, including preoperative characteristics, perioperative clinical course information, and post‐operative outcomes, were retrospectively collected from the hospital data management and quality assurance system. Descriptive and univariate analyses were performed. Among the 49 patients in this study, 28 (56.0%) survived in the first 30 days post‐operatively, and 3 died of non‐cardiac reasons later. In‐hospital mortality was significantly higher in patients with biventricular failure [P < 0.01, odds ratio (OR) 5.63] or dilated cardiomyopathy (DCM) (P = 0.02, OR 15.8), whereas ischaemic cardiomyopathy (ICM) was associated with lower mortality (P = 0.03, OR 0.24). Interestingly, the mortality was comparable between the ‘solo’ Impella group and the veno‐arterial extracorporal membrane oxygenation (va‐ECMO) plus Impella (ECMELLA) group, despite the severity of the patients' profile in the ECMELLA group (‘solo’ vs. ECMELLA; 55.6% vs. 52.6%, P = 1.00). All patients who received an additional temporary right ventricular assist device (tRVAD) were successfully weaned from va‐ECMO. Conclusions Our results suggest that biventricular failure and DCM are predictors of higher mortality in patients with Impella. Considering the pathophysiology of HF, implantation of a large Impella system seems to be promising, especially for ICM patients. The large Impella system might be more effective for better prognosis of patients under va‐ECMO, and combination therapy with tRVAD seems to be a promising strategy for early weaning from va‐ECMO.

Within the field of whole organ engineering and especially for whole heart constructs (WHC) one of many challenges still lies in overcoming technical obstacles to transfer processing and stimulation concepts that have already gained acceptance in 2D and 3D myocardial models (1,2). By their pioneering work, Ott and colleagues have shown the