Background: Post-cardiotomy cardiogenic shock (PCCS) remains a life-threatening complication after cardiac surgery. Extracorporeal membrane oxygenation (ECMO) represents the mainstay of mechanical ...circulatory support for PCCS; however, its availability is limited to larger experienced centers, leading to a mismatch between centers performing cardiac surgery and hospitals offering ECMO management beyond cannulation. We sought to evaluate the outcomes and complications of PCCS patients requiring veno-arterial (V-A) ECMO cannulated at our hospital compared to those cannulated at referral hospitals. Methods: A retrospective analysis of PCCS patients requiring V-A ECMO was conducted between October 2014 to December 2022. Results: A total of 121 PCCS patients required V-A ECMO support, of which 62 (51%) patients were cannulated at the referring institutions and retrieved (retrieved group), and 59 (49%) were cannulated at our hospital (on-site group). The baseline demographics and pre-ECMO variables were similar between groups, except retrieved patients had higher lactic acid levels (retrieved group: 8.5 mmol/L ± 5.8 vs. on-site group: 6.6 ± 5; p = 0.04). Coronary artery bypass graft was the most common surgical intervention (51% in the retrieved group vs. 47% in the on-site group). There was no difference in survival-to-discharge rates between the groups (45% in the retrieved group vs. 51% in the on-site group; p = 0.53) or in the rate of patient-related complications. Conclusions: PCCS patients retrieved on V-A ECMO can achieve similar outcomes as those cannulated at experienced centers. An established network in a hub-and-spoke model is critical for the PCCS patients managed at hospitals without ECMO abilities to improve outcomes.
A 71‐year‐old woman was admitted with acute hypoxic and hypercapnic respiratory failure and cardiogenic shock, secondary to acute on chronic biventricular systolic and diastolic congestive heart ...failure and severe aortic and mitral valve stenosis. She further presented with pulmonary hypertension and moderate‐to‐severe tricuspid regurgitation requiring high and increasing doses of vasopressors. The patient was percutaneously cannulated for venoarterial extracorporeal membrane oxygenation (VA‐ECMO) and stabilized on ECMO, with a urine output of 17.3 L within the following 8 days. Balloon valvuloplasty and/or transcatheter aortic valve replacement were discussed but ruled out by the multidisciplinary team considering the mitral valve could not be fully addressed. Though lung function was not fully optimized, a window of opportunity was identified and used for double valve replacement on day 8 of VA‐ECMO support. After a 24‐hour vasoplegic period, the patient was extubated to continuous positive airway pressure and further transitioned to nasal cannula, following which she recovered well.
Cardiogenic shock (CS) is often associated with a high risk of morbidity and mortality, and short-term mechanical circulatory support (MCS) can be a life-saving treatment. In this report, we describe ...our experience with the percutaneous left ventricular assist devices (Impella 5.5) to support cardiogenic shock patients as a bridge to recovery or advanced heart failure (HF) therapies.
We retrospectively reviewed electronic medical records of 36 CS patients supported by Impella 5.5 at our institution from May 2020 to December 2021. Baseline patient characteristics, pre-implant laboratory values, duration of support, ICU and hospital length of stay (LOS) were evaluated. Outcomes including weaning of Impella 5.5, survival to discharge, morbidity and mortality were collected.
A total of 36 patients were included in this study (Table 1). The mean age was 57 years ± 12, and 72% were male. The etiology of cardiogenic shock included non-ischemic cardiomyopathy in 12 (33%) patients, ischemic cardiomyopathy in 7 (19%), mixed in 1 (3%), acute myocardial infarction in 8 (22%), post-cardiotomy shock in 5 (14%), and myocarditis in 3 (8%). The Mean duration of support was 21 days ± 24 (median=12.5 days; 2-138), with a mean Hospital LOS of 40 days ± 30 (3-152) and mean ICU days of 33 days ± 26 (3-144). Of the 36 patients, 15 (42%) were transitioned to advanced HF therapies (LVAD=9 (25%), HTx=6 (17%)). Nine (25%) patients showed signs of myocardial recovery and were weaned, 2 patients were transferred to an outside hospital for double organ transplant, while care was withdrawn on 10 (28%) patients. Twenty-five (69%) patients survived to discharge. In 12 (33%) patients, Impella 5.5 was used as an additional tool to unload the left ventricle while on VA-ECMO. Bleeding not related to the pump (n=8, 22%) was the most common complication observed, followed by 2 (6%) cases of stroke (n=2, 6%), and one each of hemolysis (3%) and pump thrombosis (3%). Ten (28%) patients experienced pump malposition, which required adjustment under echo guidance.
Our initial short-term results demonstrate that Impella 5.5 is a reliable temporary MCS with low complication profile, with excellent survival to recovery or destination therapies. Multi-center trials are still required to validate the outcomes.
Background
With the limited number of available suitable donor hearts resulting in plateaued numbers of heart transplantations, short‐ and long‐term mechanical circulatory support devices, including ...the implantation of total artificial hearts (TAHs) are modalities that are increasingly being used as treatment options for patients with end‐stage heart failure. The superior vena cava syndrome has been described in this context in various disease processes. We report successful venoplasty for superior vena cava syndrome in a patient with a TAH.
Case Presentation
A 65‐year‐old man with a history of nonischemic cardiomyopathy had received a left ventricular assist device, and then 2 years later, underwent orthotopic heart transplantation using the bicaval anastomosis technique. The postprocedural course was complicated by primary graft failure, resulting in the need for implantation of a TAH. About 5 months after TAH implantation, he started to develop complications such as volume retention, swelling of the upper extremities, and was diagnosed to have a superior vena cava syndrome. The patient underwent a successful venoplasty of his superior vena cava by interventional radiology with resolution of upper body edema, normalization of renal, and liver function.
Conclusion
Potential fatal complications caused by catheter or wire entrapment in the right‐sided mechanical valve of a TAH have been reported. We describe a safe method for the treatment of superior vena cava syndrome in patients with TAH.
The c-Jun N-terminal kinase (JNK), a subgroup of the mitogen-activated protein kinase (MAPK) family of serine/threonine kinases, has established functions in cell growth and apoptosis. While the ...mechanisms are unclear, JNK has also been also implicated in signaling pathways that initiate cell cycle checkpoints and cell cycle progression. By following the localization of active and inactive JNK during the cell cycle, we have found that the majority of cellular JNK is soluble and present in the cytoplasm and the nucleus. Interestingly, insoluble fractions of JNK are also localized in nuclear and cytoplasmic speckles, and to the centrosomes. While JNK is associated with the centrosome throughout the cell cycle, it is only active at the centrosome from S phase through anaphase. This novel localization of centrosomal JNK is a possible link between JNK-activating stimuli and centrosome or cell cycle events.
Although survival and quality of life have improved in patients with advanced heart failure (HF) after implantation of left ventricular assist devices (LVADs), they still pose risks of ...hemocompatibility-related complications, including thrombosis and bleeding. Development of biomarkers predictive of these LVAD-associated complications could guide decision making for both clinicians and patients. Recently, we showed higher plasma TGF-β1 levels within one-week after implantation with a miniaturized mechanical-bearing axial-flow pump HeartMate II (HM-II), and reasoned that platelet activation by the rotor may have caused the release of TGF-β1 in plasma in HF patients (Mancini et al. Transl. Res. 2018; 192:15-29). Recent clinical trials with the newest LVAD, the Heartmate 3 (HM-3), which uses a fully magnetically-levitated pump, showed superior clinical outcomes, including significantly reduced incidences of pump thrombosis and stroke (Mehra et al. N Engl J Med. 2019; 380:1618-1627). In this study, we evaluated release of TGF-β1 in plasma following implantation of HM-II and HM-3 LVADs compared to either coronary artery bypass graft (CABG) surgery or extracorporeal membrane oxygenation (ECMO) therapy.
We measured serial total TGF-β1 levels in 38 Stage-D HF patients (11 received HM-II and 27 received HM-3). As a control, we collected blood samples from 10 patients undergoing CABG surgery, and 10 patients receiving ECMO therapy following acute onset cardio-pulmonary failure. Blood samples were collected before and 4-8 hours after procedures, and thereafter daily for up to one week. Plasma was prepared by centrifuging blood at 12,000 rpm for 5 min at 4°C within 10 min of blood drawing, which reduces in vitro release of TGF-β1 from platelets and thus allows accurate measurement of plasma TGF-β1. Total TGF-β1 levels were measured after acidification and neutralization of samples using DUO-ELISA kit (R&D Systems).
Baseline total plasma TGF-β1 levels were higher in HF patients before LVAD implantation than in healthy controls 4.7 ± 1.9 ng/mL in HF patients (n= 38); 3.3 ± 0.8 ng/mL in healthy controls (n= 6); p=0.006). Total TGF-β1 levels surged transiently to 14.6 ± 6.1 ng/mL within 4-8 hours after LVAD implantation (p<0.0001 compared to patients 4-12 hours after CABG surgery (3.6 ± 1.4 ng/mL) or ECMO therapy (4.9 ± 1.3 ng/mL). Interestingly, however, we found that the transient surge of TGF-β1 in HM-3 recipients was significantly lower than in HM-II recipients (Figure-1; p=0.04). TGF-β1 levels then gradually decreased and reached near basal levels 2-3 days after LVAD implantation, but remained significantly elevated in plasma of HM-II recipients until day 5 (p=0.049). TGF-β1 levels remained unchanged in both CABG and ECMO patients at all time points (Figure 1).
We conclude that LVAD implantation causes a transient surge in total plasma TGF-β1 within a few hours after the procedure, presumably due to platelet activation by LVAD, not the surgery itself, as CABG or circulating blood through ECMO did not cause the surge. The observation that a reduced initial surge and lower levels of TGF-β1 in HM-3 vs. HM-II recipients needs further investigation to determine whether these differences are due to LVAD-specific factors (different rotors causing variable shear effects) or to confounding differences in implantation procedures, such as, by-pass time, cardiac tissue injury, number of platelet transfusions, blood suction with catheters etc. or other unknown factors. Our data suggest that serial TGF-β1 measurements after LVAD implantation may serve as a surrogate biomarker for platelet activation in association with hemocompatibility-related adverse events (Uriel et al. Circ. 2017; 135:2003-2012).
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No relevant conflicts of interest to declare.
BACKGROUNDWith the limited number of available suitable donor hearts resulting in plateaued numbers of heart transplantations, short- and long-term mechanical circulatory support devices, including ...the implantation of total artificial hearts (TAHs) are modalities that are increasingly being used as treatment options for patients with end-stage heart failure. The superior vena cava syndrome has been described in this context in various disease processes. We report successful venoplasty for superior vena cava syndrome in a patient with a TAH. CASE PRESENTATIONA 65-year-old man with a history of nonischemic cardiomyopathy had received a left ventricular assist device, and then 2 years later, underwent orthotopic heart transplantation using the bicaval anastomosis technique. The postprocedural course was complicated by primary graft failure, resulting in the need for implantation of a TAH. About 5 months after TAH implantation, he started to develop complications such as volume retention, swelling of the upper extremities, and was diagnosed to have a superior vena cava syndrome. The patient underwent a successful venoplasty of his superior vena cava by interventional radiology with resolution of upper body edema, normalization of renal, and liver function. CONCLUSIONPotential fatal complications caused by catheter or wire entrapment in the right-sided mechanical valve of a TAH have been reported. We describe a safe method for the treatment of superior vena cava syndrome in patients with TAH.
Aortic valve endocarditis extending beyond the aortic root presents a particularly difficult management problem. During a four-year period we have seen four patients with extensive annular abscesses ...involving the native valve (in 1 patient) and prosthetic valves (in 3). In all these patients the aortic roots were debrided and valved conduits were replaced with coronary artery grafts while appropriate antibiotics were administered. Postoperative complications included conduction abnormalities, hemorrhage, and low cardiac output, but all 4 patients were discharged from the hospital. Two patients died, 1 of an unrelated disease at 13 months postoperatively and 1 of endocarditis at 16 months postoperatively. The two remaining patients are alive and well at 11 and 46 months postoperatively. We conclude that, in spite of the prosthetic material required, this procedure permits adequate debridement and safe reconstruction for the rare patient in whom endocarditis has resulted in aortic-ventricular discontinuity.
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