Many patients with end-stage heart failure require mechanical circulatory support as a temporizing measure to enable multidisciplinary assessment for the most suitable therapeutic strategy. Impella ...5.0 can be used as a bridge to decision to evaluate patients for potential recovery or bridge to next therapy (bridge to heart transplantation BTHT or bridge to durable left ventricular assist device or VAD BLVAD. Our goal was to examine single-center outcomes with the Impella 5.0 device as a bridge to next therapy (BTHT or BTLVAD). Forty patients underwent Impella 5.0 support from December 2009 to December 2015 with the intent of BTHT (n = 20) or BTLVAD (n = 20). The primary end point was survival to next therapy. Secondary end points included hemodynamic assessments and in-hospital/30-day complications. All patients were inotrope-dependent, with severely depressed left ventricular ejection fraction (12%) and renal insufficiency (creatinine 2.0 mg/dl). Most were Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 2 (66%) with biventricular failure (65%). Thirty patients (75%) survived to next therapy, including transplant (n = 13), durable LVAD (n = 15), and recovery of native heart function (n = 2). No strokes or major bleeding events requiring surgery were observed. Acute renal dysfunction, bleeding requiring transfusion, hemolysis, device malfunction, limb ischemia occurred in 13 (33%), 11 (28%), 3 (8%), 4 (10%), and 1 (3%) patients, respectively. Survival rate to discharge and/or 30 days was 68% (27 of 40). Temporary support with the Impella 5.0 allows for an effective bridge to decision strategy for hemodynamic stabilization and multidisciplinary heart team assessment of critically ill patients with heart failure. In conclusion, many of these patients can be subsequently bridged to the next therapy with favorable outcomes.
Objective To determine the safety, efficacy, and frequency of side graft axillary artery cannulation for extracorporeal membrane oxygenation support and compare it with other cannulation techniques. ...Methods From January 2001 to October 2011, 308 adult patients were supported with extracorporeal membrane oxygenation at a single center. In 81 patients (26.3%), the extracorporeal membrane oxygenation circuit was composed of an arterial inflow by a side graft sewn to the axillary artery. Of the 308 patients, 166 (53.9%) underwent femoral arterial cannulation and 61 (19.8%) underwent ascending aortic cannulation The pertinent variables and postprocedural events were retrospectively analyzed in this cohort of patients. Results The most common complication in the axillary artery group was hyperperfusion syndrome of the ipsilateral upper extremity (n = 20, 24.7%), followed by bleeding from the arterial outflow graft (n = 14, 17.3%). Lower extremity ischemia and fasciotomy were more frequent after femoral arterial cannulation (n = 27, 16%, and n = 18, 10.8%, respectively). The predictors for a poor in-hospital outcome for the entire group of patients were age and postoperative cerebral vascular accident. The cannulation method was not a predictor of in-hospital outcomes. Conclusions Extracorporeal membrane oxygenation support with side graft axillary artery technique was more frequently associated with hyperperfusion syndrome than other cannulation sites. Lower extremity ischemia and compartment syndrome was more common after femoral arterial cannulation.
Background Because improper airway healing continues as a source of morbidity after lung transplantation, we determined prevalence and risk factors for anastomotic complications and examined their ...impact on survival. Methods From January 1997 to January 2004, 272 patients undergoing pulmonary transplantation were studied for anastomotic airway complications. Complications were categorized as necrosis or obstruction and treatment as none, endoscopic (stenting, bronchoplasty, ablation), or open repair. Survival impact was assessed by follow-up (mean, 3.0 ± 2.2 years) using competing-risks nonproportional hazards methodology in the context of repeated events. Results By 24 months, 94 anastomotic airway complications (26 necrotic, 67 obstructive, 1 torsion) had developed in 48 patients (18%), and 23 (8.5% overall; 48% of affected patients) underwent intervention. Risk of necrotic complications preceded obstruction. Risk factors were telescoping anastomosis ( p < 0.0001), more recent transplant ( p < 0.0001), donor–recipient size mismatch ( p = 0.008), and previously treated anastomotic airway complication ( p < 0.0001). Seventy-eight interventions were performed for 60 of the 94 complications. Compared with patients experiencing no anastomotic airway complications, those with treated complications had equivalent early survival (82% versus 80% at 12 months, p = 0.9) but worse late survival (60% versus 27% at 48 months, p = 0.03), and those with untreated complications had worse early survival (82% versus 62% at 12 months, p = 0.004) but equivalent late survival ( p = 0.4). Conclusions Anastomotic airway complications occur in about one fifth of patients after lung transplantation and are formidable and persistent problems. Early complications are necrosis, followed by obstruction. Few risk factors are modifiable. Because these complications importantly affect survival, improving efficacy of intervention strategies should improve outcome.
Background Combined heart-liver transplantation (CHLT) has been utilized as a life-saving procedure in those with end-stage cardiac and hepatic pathology. Techniques and outcomes of this procedure ...are varied. We sought to review the Cleveland Clinic experience with CHLT. Methods This study is a retrospective chart review of patients who received simultaneous heart and liver transplantation between January 2006 and December 2012. Results Five patients received CHLT. The mean age was 49 (± 20) years. All cardiac pathology was nonischemic cardiomyopathy, with a mean ejection fraction of 0.36 (± 0.13). Three of the 5 were on preoperative inotropic support, 1 of which required placement of a total artificial heart for support pretransplant. Liver pathology was amyloid in 1 patient and hepatitis C in the remaining 4. Mean Model for End-Stage Liver Disease score was 17 (± 5), and mean Childs-Pugh score was 8 (± 1). Survival, now at a mean of 38 (± 20) months remains 100%, with no cardiac or hepatic graft dysfunction or episodes of rejection. One hospital readmission was required for gastroenteritis at 15 months posttransplant. Conclusions These results suggest that excellent outcomes can be achieved in this extremely sick cohort of patients, and add to the growing literature of perioperative management of CHLT recipients.
Background Left ventricular pseudoaneurysm from myocardial infarction is rare and is associated with a high risk of rapid enlargement and rupture. The purposes of this study were to describe its ...clinical presentation, assess the accuracy of diagnostic imaging modalities, and determine operative and late surgical results. Methods From January 1986 through December 2001, 30 patients aged 50 to 85 years (mean, 68; 70% male) underwent left ventricular pseudoaneurysm repair. Two surgical approaches were used: primary repair (n = 5, 17%) and patch closure (n = 25, 83%). Twenty-one patients (70%) had concomitant procedures, including coronary revascularization (n = 17, 57%) and mitral valve surgery (n = 9, 30%); 8 patients (29%) underwent emergent surgery. Clinical presentation, preoperative imaging data, and surgical outcomes were abstracted from medical records or obtained by patient follow-up. Results The most common clinical presentations were heart failure (n = 22, 73%) and angina (n = 11, 41%). Pseudoaneurysm was rarely suspected at clinical presentation. Contrast ventriculography was diagnostic in 54% of patients in whom it was performed, as opposed to 97% for two-dimensional echocardiography ( p = 0.2). Postoperative intra-aortic balloon pump was required in 7 patients (23%). Hospital mortality was 20%, and late survival was 73%, 59%, and 45% at 1, 5, and 8 years, respectively. Conclusions Left ventricular pseudoaneurysm should be suspected in postinfarction patients with unexplained heart failure. Echocardiography is usually diagnostic and is superior to ventriculography. The surgical mortality rate is elevated in this complex patient population. Long-term survival is also poor, mainly because of underlying ischemic cardiomyopathy.
Objectives This report calls attention to an unappreciated cause of both acute and chronic aortic regurgitation (AR). Background Although stenosis develops in most patients with a congenitally ...bicuspid aortic valve (BAV), in others with this anomaly, pure AR (no element of stenosis) develops, some in the absence of infection or other clear etiology. Methods We describe 5 men who underwent aortic valve replacement for pure AR associated with a BAV containing an anomalous cord attaching the raphe of the conjoined cusp near its free margin to the wall of the ascending aorta cephalad to the sinotubular junction. Results Three of these 5 patients had a history of progressive dyspnea, and the anomalous cord, which was intact at operation, appeared to cause chronic AR by preventing proper coaptation of the 2 aortic valve cusps. The other 2 patients heard a “pop” during physical exertion and immediately became dyspneic, and at operation, the anomalous cord was found to have ruptured. Prolapse of the conjoined aortic valve cusp toward the left ventricular cavity resulted in severe acute AR. Conclusions This variant of the purely regurgitant BAV may cause either chronic AR (when the anomalous cord does not rupture) or acute severe AR (when the cord ruptures).
Background Many centers are reticent to list patients for liver transplantation until coexistent cardiac disease is surgically corrected. Previous studies have documented considerable morbidity and ...mortality in liver failure patients undergoing cardiac operations. This study examined whether elective cardiac operations at the time of hepatic transplantation would yield enhanced outcomes. Methods Between July 1999 and June 2010, 10 patients underwent simultaneous liver transplantation and elective cardiac operations at a single institution. Postoperative outcomes were analyzed using a prospectively maintained database. Results The 10 patients were men (mean age, 59.8 ± 8.3 years): 7 were in Child-Pugh class B and 3 were in class C. Mean Model for End-Stage Liver Disease score was 17.0 ± 5.8. Cardiac operations included coronary artery bypass grafting in 1, aortic valve replacement in 4, coronary artery bypass grafting and aortic valve replacement in 3, coronary artery bypass grafting and mitral valve repair in 1, and tricuspid valve repair in 1. In-hospital mortality was 20%. Mean postoperative length of stay was 23 ± 8 days. Actuarial survival at 3 years was 70%. Conclusions Survival was modestly improved relative to that observed in previous studies of advanced liver failure patients undergoing heart operations without concomitant hepatic replacement. Moreover, the medium-term survival outcomes approach those documented with liver transplant alone. Further studies are warranted with this combined surgical strategy to determine if such an approach would be routinely preferable to staged repair of cardiac pathology and liver transplant.
Ventricular assist devices: The future is now Lima, Brian, MD; Mack, Michael, MD; Gonzalez-Stawinski, Gonzalo V., MD
Trends in cardiovascular medicine,
05/2015, Letnik:
25, Številka:
4
Journal Article
Recenzirano
Abstract Heart failure has become a global epidemic. For advanced heart failure, a broad assortment of device options have been introduced for both acute and prolonged intervals of hemodynamic ...assistance. Durable implantable ventricular assist devices (VADs) in particular play a key role in the management of advanced heart failure. This review focuses specifically on the current outcomes with VAD therapy, highlights the results from pivotal clinical trials, and summarizes the various device options on the market and those in preclinical development.
Body weight continues to increase worldwide due primarily to the increase in body fat. This study analyzes the frequency of massive adiposity at hearts of patients who underwent heart transplantation ...(HT) determined by the ability of the heart to float in a container of 10% formaldehyde (because adipose tissue is lighter than myocardium) and compares certain characteristics of those patients with and without floating hearts. The hearts studied at HT during a 3-year period (2013 to 2015) at Baylor University Medical Center were carefully “cleaned” and weighed by the same individual and tested as to their ability to float in a container of formaldehyde, an indication of severe cardiac adiposity. Of the 220 hearts studied, 84 (38%) floated in a container of formaldehyde and 136 (62%) did not. Comparison of the 84 patients with floating hearts to the 136 with nonfloating hearts showed a significant difference in ages, but a nonsignificant difference in gender, body mass index, frequency of systemic hypertension, or diabetes mellitus. The odds of a heart being a floating one was increased in patients with a diagnosis of ischemic cardiomyopathy (unadjusted odds ratio 2.12, 95% CI 1.21 to 3.70). The frequency of massive cardiac adiposity in the native hearts of patients having HT (38%) is striking and appears to have increased in frequency in the recent decades.
Abstract Heart transplantation (HT) increases at some centers each year and decreases at others. We examined characteristics of patients having HT at the same hospital in 2 different time periods ...(1997-2012 and 2013-2015) by 2 different surgical groups. We compared certain clinical and morphological finding in 291 patients having HT 1997 - 2012 to finding in 228 other patients having HT from 2013 - 2015. Several significant (p < 0.05) differences were found: in the most recent time period (2013-2015) compared to the earlier time period (1997-2012), the mean ages of the men were older (57 years -vs- 55 years); diabetes mellitus was more frequent (37% -vs- 21%); systemic hypertension (by history) was more frequent (59 % -vs- 32%); the mean body mass index was higher (29.2 kg/m2 -vs- 26.5 kg/m2 ), and mean heart weight was lower in both men (509 g -vs- 549 g) and women (422 g -vs- 454 g). There were insignificant (p> 0.05) differences in gender, frequency of massive cardiac adiposity, underlying cardiac condition, frequency of coronary heart disease, and frequency of previous insertion of a left ventricular assist device. In conclusion, certain characteristics of patients having HT at one Texas hospital changed in several respects in 2 time periods corresponding to changes in surgeons doing the HTs.
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