[Basic standards for a department of cardiac surgery. Quality requirements for the care of cardiac patients in connection with operations on the heart, the heart vessels and thoracic organ transplantation]

Current evolutions and substantial amendments of the German health care system in combination with distinguished progress in cardiac surgery over the past years require both a reflection of principles in patient-centered care and an update of basic standard requirements for a department of cardiac surgery in Germany. In due consideration of the data from the voluntary registry of the German Society for Thoracic and Cardiovascular Surgery, this article accurately defines core requirements for a cardiac surgical department (cardiac surgery on-site), subdivided into facilities, staff and processes. If based on these standards, one may anticipate that cardiac surgical care is performed under appropriate conditions leading to an intrinsic benefit for patients.

The German Aortic Valve Registry (GARY): in-hospital outcome

BACKGROUND

Aortic stenosis is a frequent valvular disease especially in elderly patients. Catheter-based valve implantation has emerged as a valuable treatment approach for these patients being either at very high risk for conventional surgery or even deemed inoperable. The German Aortic Valve Registry (GARY) provides data on conventional and catheter-based aortic procedures on an all-comers basis.

METHODS AND RESULTS

A total of 13 860 consecutive patients undergoing repair for aortic valve disease [conventional surgery and transvascular (TV) or transapical (TA) catheter-based techniques] have been enrolled in this registry during 2011 and baseline, procedural, and outcome data have been acquired. The registry summarizes the results of 6523 conventional aortic valve replacements without (AVR) and 3464 with concomitant coronary bypass surgery (AVR + CABG) as well as 2695 TV AVI and 1181 TA interventions (TA AVI). Patients undergoing catheter-based techniques were significantly older and had higher risk profiles. The stroke rate was low in all groups with 1.3% (AVR), 1.9% (AVR + CABG), 1.7% (TV AVI), and 2.3% (TA AVI). The in-hospital mortality was 2.1% (AVR) and 4.5% (AVR + CABG) for patients undergoing conventional surgery, and 5.1% (TV AVI) and AVI 7.7% (TA AVI).

CONCLUSION

The in-hospital outcome results of this registry show that conventional surgery yields excellent results in all risk groups and that catheter-based aortic valve replacements is an alternative to conventional surgery in high risk and elderly patients.

Mobility, fitness collection, and the breakdown of cooperation

The spatial arrangement of individuals is thought to overcome the dilemma of cooperation: When cooperators engage in clusters, they might share the benefit of cooperation while being more protected against noncooperating individuals, who benefit from cooperation but save the cost of cooperation. This is paradigmatically shown by the spatial prisoner's dilemma model. Here, we study this model in one and two spatial dimensions, but explicitly take into account that in biological setups, fitness collection and selection are separated processes occurring mostly on vastly different time scales. This separation is particularly important to understand the impact of mobility on the evolution of cooperation. We find that even small diffusive mobility strongly restricts cooperation since it enables noncooperative individuals to invade cooperative clusters. Thus, in most biological scenarios, where the mobility of competing individuals is an irrefutable fact, the spatial prisoner's dilemma alone cannot explain stable cooperation, but additional mechanisms are necessary for spatial structure to promote the evolution of cooperation. The breakdown of cooperation is analyzed in detail. We confirm the existence of a phase transition, here controlled by mobility and costs, which distinguishes between purely cooperative and noncooperative absorbing states. While in one dimension the model is in the class of the voter model, it belongs to the directed percolation universality class in two dimensions.

Transapical mitral valve implantation: the Lutter valve

  The development of transcatheter techniques for treatment of severe mitral valve regurgitation in the beating heart is focus of recent research. An off-pump treatment technique poses great benefits, particularly for multimorbid patients, often being non-compliant to the gold standard treatment, being open heart surgery with use of a cardiopulmonary bypass. Thereto, two approaches are being followed: transcatheter valve repair and transcatheterimplantation of a valved stent into the native mitral valve annulus. A valved stent has to provide safe and secure fixation within the high pressure system of the left heart. One of the main challenges in the development of such a valved stent is the complex anatomy of the mitral valve, with no clearly defined structures for device anchorage. Our group has developed a self-expanding nitinolvalved stent for transapical implantation in the beating heart. During the development process of thevalved stent, different design iterations were conducted to decrease the risk of paravalvular leakages, to enhance the reproducibility and to improve the overall stent performance. This article reviews the major milestones passedin the development process of our mitral valved stent and advances achieved withinthe last years. Multiple design iterations lead to a prototype providing secure stent deployment, hig h reproducibility, low paravalvular leakages and only mild stent deformation in the beating heart. In future, further long-term in vivo trials have to be conducted before attempting the step towards clinical application of this novel device.

Another possible food-borne outbreak of hepatitis A in the Netherlands indicated by two closely related molecular sequences, July to October 2011

In November 2011, a cluster of initially five cases of hepatitis A infection with closely related strains was identified in the Netherlands. England reported possibly related cases. Strains with identical sequences had been involved in previous outbreaks linked to semi-dried tomatoes. Investigation of the Dutch cluster suggested a link with ready-to-eat salads including those containing semi-dried tomatoes. Despite trace-back, a source was not identified. Vigilance is needed, and rapid sharing of data may help source-tracing.