In 41 patients undergoing cardiac Operations with extracorporeal circulation, oxidized cytochrome a,a3 (CtO₂), deoxygenated hemoglobin (Hb), and oxygenated hemoglobin (HbO₂) were measured in brain tissue by near-infrared spectrophotometry (NIRS) intraoperatively. Monitoring also included electroencephalography (EEG) and jugular-bulb venous Saturation (S_BJO₂). All Operations were performed using membrane oxygenators, moderate hypothermia (26-28 °C) and pH alpha-stat management. During cardiopulmonary bypass (CPB) CtO₂ and HbO₂ were reduced, reaching minimal values when rewarming was instituted. At the end of the Operation CtO₂ and HbO₂ had regained initial levels. During CPB, arterial Pco₂, pH, and temperature were closely related to CtO₂ (r =1000, r = -0.964 and 0.929 respectively; p < 0.001, p < 0.001, and p < 0.003 respectively). Neuropsychological testing by the Mini-Mental-State Test indicated reversible postoperative neuropsychological deficits in four patients. These patients had a lower CtO₂ minimum compared to those without these deficits (∼4.5 μmol/L v. -0.7 μmol/L; p = 0.036). These findings support the hypothesis that neuropsychological deficits in patients after cardiac surgery can be caused by intraoperative cerebral hypoxia. Bei 41 Patienten wurden während herzchirurgischer Operationen mit der extrakorporalen Zirkulation (EKZ) oxydiertes Cytochrom a,a3 (CtO₂), deoxygeniertes Hämoglobin (Hb) und oxygeniertes Hämoglobin(HbO₂) im Hirngewebe durch Nah-Infrarot-Spektrophotometrie (NIRS) gemessen. Weiterhin wurden das Elektroenzephalogramm (EEG) und die venöse Sauerstoffsättigung im Bulbus jugularis überwacht. Alle Operationen wurden mit Membranoxygenatoren, moderater Hypothermie und pH Alpha-Stat-Management vorgenommen. Während der EKZ waren CtO₂ und HbO₂ reduziert; diese Parameter erreichten minimale Werte zu Beginn des Wiederaufwärmens. Am Ende der Operation erreichten CtO₂ und HbO₂ Ausgangswerte. Während der EKZ zeigten PcO₂. pH und Temperatur enge Relationen zum CtO₂ (r = 1,000, r = -0,964 und r = 0.929 respektive: p < 0,001, p<0.001 und p<0.003 respektive). Die neuropsychologische Testung mit dem Mini-Mental-State-Test zeigte reversible neuropsychologische Defizite bei vier Patienten. Diese Patienten wiesen niedrigere CtO₂-Minima auf als die Patienten ohne Defizite (∼4,5 μmol/L v. -0,7 μmol/L; p - 0,036). Die Ergebnisse stützen die Hypothese, daß neuropsychologische Defizite bei Patienten nach herzchirurgischen Operationen durch intraoperative Hypoxie verursacht sein können.

In the pediatric age group shortage of donor hearts leads to mortality rates of 30-50% on the waiting list. Because of the immaturity of the immune system of infants, ABO-incompatible heart transplantation may be an option to increase donor availability. We transplanted two infants with blood type O at the age of 7 and 5 months, respectively, with complex congenital heart disease. Intraoperative plasma exchange was performed during cardiopulmonary bypass followed by standard immunosuppression. Both recipients received a blood type A donor organ. Plasma was exchanged up to six times until anti-A antibodies were eliminated. No hyperacute rejection occurred, ventricular function is excellent and there have been no acute rejection episodes up to 4 months after transplantation. Anti-A antibody titers remained low and eventually disappeared. ABO-incompatible cardiac transplantation shows good short-term results in young infants and appears to be a safe procedure to reduce mortality on the waiting list.

Intraoperative antithrombotic drug removal by haemoadsorption is a novel strategy to reduce perioperative bleeding in patients on antithrombotic drugs undergoing cardiac surgery. The international STAR registry reports real-world clinical outcomes associated with this application. All patients underwent cardiac surgery before completing the recommended washout period. The haemoadsorption device was incorporated into the cardiopulmonary bypass (CPB) circuit. Patients on P2Y₁₂ inhibitors comprised group 1, and patients on direct-acting oral anticoagulants (DOAC) group 2. Outcome measurements included bleeding events according to standardised definitions and 24-hour chest-tube-drainage (CTD). 165 patients were included from 8 institutions in Austria, Germany, Sweden, and the UK. Group 1 included 114 patients (62.9 ± 11.6years, 81% male) operated at a mean time of 33.2 h from the last P2Y₁₂ inhibitor dose with a mean CPB duration of 117.1 ± 62.0 min. Group 2 included 51 patients (68.4 ± 9.4years, 53% male), operated at a mean time of 44.6 h after the last DOAC dose, with a CPB duration of 128.6 ± 48.4 min. In Group 1, 15 patients experienced a BARC-4 bleeding event (13%), including 3 reoperations (2.6%). The mean 24-hour CTD was 651 ± 407mL. In Group 2, 8 patients experienced a BARC-4 bleeding event (16%) including 4 reoperations (7.8%). The mean CTD was 675 ± 363mL. This initial report of the ongoing STAR registry shows that the intraoperative use of a haemoadsorption device is simple and safe, and may potentially mitigate the expected high bleeding risk of patients on antithrombotic drugs undergoing cardiac surgery before completion of the recommended washout period.Clinical registration number: ClinicalTrials.gov identifier: NCT05077124. Graphical Abstract

Objective: This analysis was undertaken to evaluate the results of persistent atrial fibrillation (pAF) ablation procedures concomitant to coronary surgery and to identify the risk factors for pAF recurrence. Methods: Since 2001, a total of 126 consecutive patients with pAF (duration: 0.5–33 years) underwent ablation concomitant to coronary surgery (isolated or in combination with valve surgery), whereby two encircling isolation lesions around the left and the right pulmonary veins and a connecting lesion between both was created using radiofrequency ablation. Patients were reevaluated at discharge, 3 months and 3 years after surgery. Results: Survivals at the time of reexamination were 96.8, 95.1 and 94.7 %, respectively. Stable sinus rhythm (SR) could be documented in 66.4, 75.1 and 75.9 % of surviving patients. Long-term pAF before surgery and a larger left atrium (LA) were predictive of postoperative pAF return (p < 0.01). Statistical analysis demonstrated a cut-off point of 5 years for pAF and 50 mm for LA diameter: 89.1 % of patients with pAF duration of < 5 years and 86.2 % of patients with LA size of ≤ 50 mm were in stable SR at late follow-up. Cardiac rhythm at 3 months was predictive for long-term rhythm prognosis (p < 0.01). Age, gender and concomitant diseases (e.g. arterial hypertension, diabetes, renal insufficiency), and the underlying cause of heart disease did not significantly influence the postoperative cardiac rhythm. Conclusions: The duration of pAF and the LA size are the most reliable preoperative variables to predict the success rate of ablation in patients undergoing coronary surgery. The probability of re-establishing stable SR is excellent when pAF duration is short and LA size is small. 1 Presented at the 39^th Annual Meeting of the German Society for Thoracic and Cardiovascular Surgery, Stuttgart, February 14–17, 2010 (V 171).

The objectives of this study were to identify: (1) the indications for pacemaker implantation; (2) the long-term survival; (3) the percentage of bradyarrhythmias below 50 beats/min persisting for more than 3 months; and (4) the variables predicting persistent bradyarrhythmias following orthotopic heart transplantations. During the recent decade (August 1, 1981 through December 31, 1991), 237 patients underwent orthotopic heart transplantation at our institution. Twenty-six recipients (11%) showed evidence of a symptomatic bradyarrhythmia due to sinus node dysfunction (n = 25) or complete heart block (n = 1), which required insertion of a permanent pacing device. During a mean follow-up period of 17.2 months (range 3 to 57 months), five patients (19%) died and one was lost to follow-up. Actuarial survival at 1 and 4 years were 81% and 65%, respectively, as compared to 79% and 69%, respectively, in patients without permanent pacemakers. Holter monitoring after 3 months (n = 25) and 1 year (n = 14) showed a spontaneous heart rate below 50 beats/min in six (24%) and three patients (18%), respectively. None of the tested variables predicted the necessity of initial pacemaker implantation. However, in patients requiring permanent pacing for a period longer than 3 months, ischemic time of the donor heart was found to be significantly longer as compared to the other patients (221 +/- 76 min vs 137 +/- 91 min, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

This report comprises the contents of the presentations and following discussions of a workshop of the German Heart Transplant Centers in Martinsried, Germany on cardiac xenotransplantation. The production and current availability of genetically modified donor pigs, preservation techniques during organ harvesting, and immunosuppressive regimens in the recipient are described. Selection criteria for suitable patients and possible solutions to the problem of overgrowth of the xenotransplant are discussed. Obviously microbiological safety for the recipient and close contacts is essential, and ethical considerations to gain public acceptance for clinical applications are addressed. The first clinical trial will be regulated and supervised by the Paul-Ehrlich-Institute as the National Competent Authority for Germany, and the German Heart Transplant Centers agreed to cooperatively select the first patients for cardiac xenotransplantation.