Background: Extracorporeal membrane oxygenation (ECMO) has been increasingly used for postcardiotomy cardiogenic shock, but without a concomitant reduction in observed in‐hospital mortality. Long‐term outcomes are unknown. This study describes patients’ characteristics, in‐hospital outcome, and 10‐year survival after postcardiotomy ECMO. Variables associated with in‐hospital and postdischarge mortality are investigated and reported. Methods and Results: The retrospective international multicenter observational PELS‐1 (Postcardiotomy Extracorporeal Life Support) study includes data on adults requiring ECMO for postcardiotomy cardiogenic shock between 2000 and 2020 from 34 centers. Variables associated with mortality were estimated preoperatively, intraoperatively, during ECMO, and after the occurrence of any complications, and then analyzed at different time points during a patient's clinical course, through mixed Cox proportional hazards models containing fixed and random effects. Follow‐up was established by institutional chart review or contacting patients. This analysis included 2058 patients (59% were men; median [interquartile range] age, 65.0 [55.0–72.0] years). In‐hospital mortality was 60.5%. Independent variables associated with in‐hospital mortality were age (hazard ratio [HR], 1.02 [95% CI, 1.01–1.02]) and preoperative cardiac arrest (HR, 1.41 [95% CI, 1.15–1.73]). In the subgroup of hospital survivors, the overall 1‐, 2‐, 5‐, and 10‐year survival rates were 89.5% (95% CI, 87.0%–92.0%), 85.4% (95% CI, 82.5%–88.3%), 76.4% (95% CI, 72.5%–80.5%), and 65.9% (95% CI, 60.3%–72.0%), respectively. Variables associated with postdischarge mortality included older age, atrial fibrillation, emergency surgery, type of surgery, postoperative acute kidney injury, and postoperative septic shock. Conclusions: In adults, in‐hospital mortality after postcardiotomy ECMO remains high; however, two‐thirds of those who are discharged from hospital survive up to 10 years. Patient selection, intraoperative decisions, and ECMO management remain key variables associated with survival in this cohort. Registration: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03857217.

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.

Background: The indications for intra-aortic balloon pump (IABP) in the case of a failing right ventricle after operations with extracorporeal circulation (ECC) are still discussed controversially. We investigated the benefit of IABP in patients with a predominantly right ventricular dysfunction after ECC. Additionally, we wanted to identify early and easily available prognostic markers for outcome in all patients receiving IABP support. Patients and Methods: Between 1/2004 and 1/2008, 4550 patients underwent cardiac surgical procedures with ECC, 223 of whom (4.9 %) had an IABP inserted intra- or postoperatively (group 1). 79 of these patients were treated intraoperatively with IABP for early postoperative low cardiac output syndrome (LCOS) characterized by predominantly right ventricular failure (RV group). Clinical data and hemodynamic variables were recorded perioperatively. Multiple potential markers of mortality and postoperative complications were analyzed statistically, especially with regard to their predictive ability. Results: 68 % of all IABP patients were successfully weaned from IABP support and 63 % survived to hospital discharge. In the RV group, cardiac index (CI) and mean arterial pressure (MAP) increased (CI 1.8 ± 0.2 to 2.8 ± 0.2, MAP 53 ± 10 to 73 ± 8, p < 0.05) within 1 hour after IABP, whereas central venous pressure (CVP) and pulmonary artery wedge pressure (PAWP) decreased (p < 0.05). 59 patients in the RV group (75 %) could be weaned from IABP successfully and 69 % survived to hospital discharge. Serum lactate of more than 11 mmol/L in the first 10 hours of IABP support predicted a 100 % mortality. A base deficit of more than 12 mmol/L, mean arterial pressure less than 55 mmHg, urine output of less than 50 ml/h for 2 hours, and dose of epinephrine or norepinephrine of more than 0.4 mg/kg/min were other highly predictive prognostic markers. Furthermore, multivariate analysis showed that patients with a left atrial pressure > 17 mmHg or a mixed venous saturation (SVO₂) < 65 % had poor outcomes. Conclusions: In patients with IABP support for postcardiotomy cardiogenic shock, elevated serum lactate, elevated base deficit, hypotension, oliguria and large vasopressor doses are all predictors of mortality. In these patients, the use of another mechanical assist device should be considered in good time. Our study additionally shows that LCOS caused by predominantly right ventricular failure – particularly after CABG – may be an additional indication for IABP. 1 The results of this paper were presented in part during the 5th joint meeting of the German, Austrian and Swiss Societies of Thoracic- and Cardiovascular Surgery, February 17–20, 2008 in Insbruck/Austria as oral presentation.

Cardiopulmonary bypass (CPB) is a commonly used technique in cardiac surgery. CPB is however associated with a strong induction of systemic inflammatory response syndrome (SIRS) which in conjunction with ischemia and reperfusion may lead to multiple organ failure. The aim of the study was to establish and characterize a CPB rat model incorporating deep hypothermic circulatory arrest with a specific focus on the extent of the inflammatory reactions and organ damage as a groundwork for novel therapeutics against SIRS and I/R induced organ injury. Male Wistar rats (n = 6) were cannulated for CPB, connected to a heart-lung-machine (HLM) and cooled to a temperature of 16°C before they underwent 45 minutes of deep hypothermic circulatory arrest with global ischaemia. Arrest was followed by rewarming and 60 minutes of reperfusion. Haemodynamic and vital parameters were recorded throughout the CPB procedure. Only animals displaying sinus rhythm throughout reperfusion were utilized for analysis. Rats were euthanized and tissue samples were harvested. Blood gas analysis was performed and blood samples were taken. Induction of organ damage was examined by analysis of protein levels and phosphorylation status of kinases and stress proteins. Results were compared to animals (n = 6) which did not undergo CPB. CPB induced leucocytosis and an increase of interleukin-6 and TNF-α plasma values indicating an inflammatory response. Markers of tissue damage and dysfunction, such as troponin T, creatinine and AST were elevated. Phosphorylation of STAT3 was induced in all examined organs. Activation of MAPK and induction of heat shock proteins occurred in an organ-specific manner with most pronounced effects in heart, lungs and kidneys. The presented CPB rat model shows the induction of SIRS and activation of specific signalling cascades. SIRS seems not to be provoked during DHCA and is elicited mainly during reperfusion. This model might be suitable to test the efficacy of therapeutics applied in major heart surgery with and without DHCA.

Changes in the age profile of the population in the western world and improvement in surgical techniques and postoperative care have contributed to a growing number of cardiosurgical patients aged over 90. In periods when transapical and transfemoral aortic valve replacement were done, we aimed at evaluating the outcome of nonagenarians after conventional aortic valve replacement and cardiac surgery in general, and determining perioperative parameters to predict a complicated postoperative course. Between 1995 and 2011, 49 nonagenarians (aged 91.2 ± 3.1 years) underwent cardiac surgery. A subgroup of 30 patients received aortic valve replacement alone (63%; n = 19), in combination with coronary artery bypass grafting (27%; n = 8) or other surgical procedures (10%; n = 3). Most of the patients suffered from combined aortic valve disease with a mean valve orifice area of 0.6 ± 0.3 cm² and a mean antegrade pressure gradient of 86 ± 22 mmHg. Cardiac surgery in nonagenarians resulted in remarkable postoperative morbidity and an overall in-hospital mortality of 10% (n = 5). In the AVR subgroup, biological valve prostheses were implanted in 29 patients. In this subgroup, the length of stay was 2.9 ± 0.9 days in the intensive care unit and 17.0 ± 5.5 days in the hospital. The in-hospital mortality amounted to 13% (n = 4). Although several general preoperative risk factors of postoperative complications such as renal failure, low cardiac output syndrome and New York Heart Association Class IV were remarkably more frequent among the patients who died after the operation, the small cohort of non-surviving nonagenarians did not allow for significant differences. Cardiac surgery in the very elderly, particularly with regard to aortic valve replacement, carries a high risk of early morbidity and mortality. However, in selected nonagenarians, surgery can be performed with an acceptable outcome. The risk may even be reduced by an individual approach to the procedure. With regard to potential risk factors, the selection of these patients should be carried out very carefully.

Since it is of great importance to distinguish between a systemic inflammatory response syndrome (SIRS) and an infection caused by microbes especially after heart transplantation (HTX), we examined patients following heart surgery by determining procalcitonin (PCT), because PCT is said to be secreted only in patients with microbial infections. Sixty patients undergoing coronary artery bypass grafting (CABG) and 14 patients after heart transplantation were included in this prospective study. In the CABG group we had 30 patients without any postoperative complications (group A). Furthermore we took samples of 30 patients who suffered postoperatively from a sepsis (group B, n=15) or a systemic inflammatory response syndrome (C, n=15). In addition we measured the PCT-levels in 65 blood samples of 14 patients after heart transplantation (Group I: rejection > IIa, II: viral infection (CMV), III: bacterial/fungal infection, IV: controls). In all patients of group A the pre- and intraoperative PCT-values and the measurement at arrival on intensive care unit (ICU) were less than 0.2 ng/ml. On the second postoperative day the PCT-value was 0.33+/-0.15 ng/ml in the control group. At the same time it was 19.6+/-6.2 ng/ml in sepsis and 0.7+/-0.4 ng/ml in systemic inflammatory response syndrome patients (P<0.05). In transplanted patients we could find the following PCT-values: Gr.I: 0.18+/-0.06 II: 0.30+/-0.09 III: 1.63+/-1.16 IV: 0.21+/-0.09 ng/ml (P<0.05 comparing group III with I, II and IV). These results show that extracorporeal circulation (ECC) and systemic inflammatory response syndrome do not initiate a PCT-secretion. Septic conditions cause a significant increase of PCT. In addition, PCT is a reliable indicator concerning the essential differentiation of bacterial or fungal--not viral--infection and rejection after heart transplantation.