A bridge to transplantation: The life experiences of patients with a left ventricular assist device.

BACKGROUND: The Left Ventricular Assist Device (LVAD) is a rapidly spreading treatment given to patients with advanced heart failure due to organ donor shortage. Thus, there is a need to study the life experience of patients who underwent LVAD implantation as a bridge to transplantation. OBJECTIVE: To examine the life experiences of patients who underwent LVAD implantation as a bridge to transplantation. METHODS: This qualitative, phenomenological research was carried out with 13 patients who underwent LVAD implantation as a bridge to transplantation. Data were collected through semi-structured in-depth interviews. Interviews were recorded through an audio recorder, transcribed verbatim, and evaluated using the inductive content analysis method. RESULTS: Two main themes (fear and coping), each with four sub-themes, were obtained after data were analyzed. Participants' fears and coping strategies for these were identified. CONCLUSION: In this study, fears and coping strategies came to the forefront in the life experiences of patients who underwent LVAD implantation as a bridge to transplantation.

Early postoperative rupture of Heartware outflow graft: A case report.

We know that new generation left ventricular assist devices (LVAD), significantly reduce the mortality of patients in the treatment of advanced heart failure disease, compared to optimal medical therapy. Day by day, we treat more heart failure patients with LVADs. Patients that can be cured are on the rise. But this also causes us to struggle with more complications. In this article, we present a case of cardiac tamponade due to rupture that occurred in the outflow graft of HeartWare left ventricular assist device (HVAD), a complication encountered for the first time as far as we know.

Extracorporeal Membrane Oxygenation Therapy-Assisted Cardiopulmonary Resuscitation and Successful Bridging to Cardiac Retransplant for Cardiac Allograft Vasculopathy.

Extracorporeal membrane oxygenation therapy is being used increasingly in different areas. It has become an indispensable assistant to clinicians for hypoxic pulmonary disorders, cardiogenic shock, resuscitation, and during cardiac surgery. In this case report, we describe a patient who is bridged to successful cardiac retransplant under extracorporeal membrane oxygenation therapy support after extracorporeal membrane oxygenation therapy-assisted cardiopulmonary resuscitation.

Cardiac Tamponade Due to Pneumopericardium After Liver Transplant.

Pneumopericardium is a rare cause of cardiac tamponade, and it is an extremely rare complication of liver transplant. Here, we present a patient with cryptogenic liver cirrhosis who experienced cardiac tamponade secondary to a tension pneumopericardium during the postoperative course after liver transplant.

First successful percutaneous treatment of a totally occluded HeartWare outflow graft: Case report and literature review.

As the number of implanted left ventricular assist devices (LVADs) used increases, the frequency of chronic complications encountered also increases. The pause of blood flow in the outflow graft is a rare, but fatal, complication. The aim of this article was to present the case of a patient in whom HeartWare outflow graft occlusion was removed by balloon angioplasty and to examine the treatment modalities of HeartWare outflow graft occlusions that have been percutaneously performed to date. The literature was searched for percutaneous interventions on outflow grafts of the left ventricular assist devices. The results of six patients who underwent interventions on outflow grafts were analyzed. Three of six patients with HeartWare outflow graft stenosis were treated with covered stents, while the remaining three were treated with bare metal stents. All procedures were applied successfully. Percutaneous interventions can be performed with appropriate equipment in patients with HeartWare outflow graft stenosis or total occlusion.

Early thrombus formation in patient with HeartWare left ventricular assist device presenting with acute heart failure.

Heart failure is one of the leading causes of mortality and morbidity in the world. Heart transplantation is still the gold standard therapy despite emerging treatment options. Due to the limited number of available donors, the use of ventricular assist devices has increased. However, increasing incidences of complications are observed with using these devices. In this article, surgical treatment of a huge mobile thrombus formation in an inflow cannula due to ineffective anticoagulation in a 59 year-old man who received a HeartWare ventricular assist device because of ischemic cardiomyopathy is presented.

Endovenous laser with miniphlebectomy for treatment of varicose veins and effect of different levels of laser energy on recanalization. A single center experience.

Varicose veins, associated with great saphenous vein (GSV) incompetence, are traditionally treated with conventional surgery. In recent years, minimally invasive alternatives to surgical treatment such as the endovenous laser ablation (EVLA) and radiofrequency (RF) ablation have been developed with promising results. Residual varicose veins following EVLA, regress untouched, or phlebectomy or foam sclerotherapy can be concomitantly performed. The aim of the present study was to investigate the safety and efficacy of EVLA with different levels of laser energy in patients with varicose veins secondary to saphenous vein reflux. From February 2006 to August 2011, 740 EVLA, usually with concomitant miniphlebectomies, were performed in 552 patients. A total of 665 GSV, 53 small saphenous veins (SSV), and 22 both GSV and SSV were treated with EVLA under duplex USG. At 84 patients, bilateral intervention is made. In addition, miniphlebectomy was performed in 540 patients. A duplex ultrasound (US) is performed to patients preoccupying chronic venous insufficiency (with visible varicose veins, ankle edema, skin changes, or ulcer). Saphenous vein incompetence was diagnosed with saphenofemoral, saphenopopliteal, or truncal vein reflux in response to manual compression and release with patient standing. The procedures were performed under local anesthesia with light sedation or spinal anesthesia. Endovenous 980-nm diode laser source was used at a continuous mode. The mean energy applied per length of GSV during the treatment was 77.5 ± 17.0 J (range 60-100 J/cm). An US evaluation was performed at first week of the procedure. Follow-up evaluation and duplex US scanning were performed at 1 and 6 months, and at 1 and 2 years to assess treatment efficacy and adverse reactions. Average follow-up period was 32 ± 4 months (3-55 months). There were one patient with infection and two patients with thrombus extension into the femoral vein after EVLA. Overall occlusion rate was 95%. No post-procedural deep venous thrombosis or pulmonary embolism occurred. Laser energy, less than 80 J/cm, was significantly associated with increased recanalization of saphenous vein, among the other energy levels. EVLA seems a good alternative to surgery by the application of energy of not less than 80 J/cm. It is both safe and effective. It is a well-tolerated procedure with rare and relatively minor complications.

Outcomes of combined cardiac surgery and kidney transplant compared with kidney transplant after cardiac surgery.

CONTEXT: Patients with chronic renal failure have a high prevalence of coronary artery disease and cardiovascular death. The mortality and the morbidity rates of cardiac surgery are particularly high in these patients with end-stage renal disease. Performing cardiac surgery and kidney transplant in the same session can reduce these complications in the early postoperative period by normalizing renal function. OBJECTIVE: To compare the mortality and morbidity rates between patients who had undergone cardiac surgery and kidney transplant separately and patients who had combined surgeries. METHODS: This retrospective study consisted of 75 patients. One group of 60 patients underwent cardiac surgery and kidney transplant in separate sessions, and the other group of 15 patients had combined surgeries in the same session, between March 2008 and September 2012. RESULTS: Patients who had combined surgeries achieved fluid electrolytic balance more easily, had shorter extubation times, used less blood and blood products, and had fewer major complications. The patients recovered faster and thus had shorter stays in the intensive care unit and hospital. This combined surgical approach allows normalized kidney function in patients with end-stage renal disease, so mortality and morbidity in the early postoperative period could be significantly reduced.

A case report on concomitant coronary artery bypass operation and renal transplantation.

Renal transplantation is successfully implemented in patients undergoing coronary bypass surgery. We performed concomitant coronary bypass surgery and renal transplantation in a patient found to have a left main coronary artery lesion after coronary angiography, which was performed in our clinic during preoperative evaluation of renal transplantation. We suggest the application of coronary-artery bypass grafting (CABG) or stent implantation 2 months after renal transplantation in asymptomatic patients with coronary artery disease. But, if severe coronary artery disease is detected in symptomatic patients, we suggest the concurrent application CABG and renal transplantation.

The effect of partial cross clamping administration on postoperative healing of pulmonary functions for coronary artery bypass graft operations.

OBJECTIVE: To compare partial cross clamping and mechanic pulmonary ventilation technique with total cross clamping utilization during cardiopulmonary bypass in coronary artery bypass graft operations in terms of pulmonary healing. METHODS: Between February and April 2007, isolated coronary artery bypass graft operation was performed for 30 patients in the Cardiovascular Surgery Department, Erzurum Regional Training and Research Hospital, Erzurum, and the Cardiovascular Surgery Department, Medical Faculty, Akdeniz University, Antalya, Turkey. The patients were divided into 2 groups; Group A (n=15) with total cross clamping, and Group B (n= 15) partial cross clamping and mechanic pulmonary ventilation in cardiopulmonary bypass. RESULTS: Postoperative pulmonary functions were studied in 2 main data; 1) the oxygenization rate of artery blood gas, and 2) spirometer results. Additionally, total cardiopulmonary bypass and total cross-clamping times, extubation times, numbers and types of grafts, days of intensive care unit treatment, and hospitalizations were recorded. There was no statistically significant difference between the 2 groups for oxygenization rate, and surgery hospitalization details. We observed a statistically significant difference with advantage in Group B in spirometric results in terms of healing of pulmonary functions. CONCLUSION: Total cross clamping and circulatory arrest of the lungs are the main sources of postoperative pulmonary complications based on the pulmonary inflammatory response in coronary artery bypass surgery.

Exceptional ventricular septal rupture associated with intramyocardial dissection throughout the right ventricle.

Ventricular septal rupture (VSR) is an uncommon but a devastating complication of acute myocardial infarction. Wide implementation of thrombolytic therapy in practice has limited the incidence of this complication and changed its time pattern by accelerating the occurrence. In the era of primary percutaneous coronary intervention, this beneficial effect is more pronounced. This paper describes a case with a complex VSR with intramyocardial dissection tract extending throughout the right ventricle and yielding a left to right shunt; where the potential role of ischemia was suspected, but the precise etiology of septal rupture remained ambiguous.

Surgical treatment of left ventricular aneurysms: a comparison of long-term follow-up of left ventricular function for classic aneurysmectomy and endoaneurysmorrhaphy techniques.

OBJECTIVE: Myocardial infarction may be complicated by the formation of a left ventricular (LV) aneurysm that distorts the normal elliptical geometry of the ventricle to produce a dilated spherical ventricle with limited contractile and filling capacities. One of the consequences is congestive heart failure, which may be refractory to medical therapy and require surgical treatment. The aim of this study was to evaluate LV function in the late term following repair of LV aneurysm. METHODS: Ninety-seven patients underwent repair of postinfarctional LV aneurysms. Sixty-one patients (62.9%) underwent classic aneurysmectomy, and 36 patients (37.1%) had endoaneurysmorrhaphy. The mean age (+/-SD) of the 87 men (89.7%) and 10 women was 55.98 +/- 8.59 years. Coronary surgery was performed in 82 patients (84.5%), with a mean of 1.34 +/- 0.77 grafts/patient. The mean preoperative ejection fraction (EF) was 39.74% +/- 8.79% (classic, 39.92% +/- 8.90%; endoaneurysmorrhaphy, 39.43% +/- 8.61%; difference not statistically significant [NS]). Fifty-five patients (56.7%) had angina of Canadian Cardiovascular Society class III to IV (classic, 55.7%; endoaneurysmorrhaphy, 58.3%; NS), 31 patients (31.9%) were in New York Heart Association (NYHA) class III to IV (classic, 31.1%; endoaneurysmorrhaphy, 33.3%; NS), and the mean preoperative NYHA functional class was 2.88 +/- 0.74 (classic, 2.83 +/- 0.77; endoaneurysmorrhaphy, 2.97 +/- 0.71; NS). RESULTS: The mortality rate at <30 days was 9.8% (n = 6) in the classic aneurysmectomy group and 2.7% (n = 1) in the endoaneurysmorrhaphy group. Long-term follow-up was available for 80 of these patients. During a mean follow-up of 79.3 +/- 37.6 months (range, 6-156 months), 14 patients (17.5%) died of a cardiac-related cause (classic, 8 patients [16.6%]; endoaneurysmorrhaphy, 6 patients [18.7%]; NS). The cardiac-related survival rate was 82.5%. In the first year, at 5 years, and at 10 years, the survival rates of the patients who underwent classical aneurysmectomy were 98.8%, 93.5%, and 76.1%, respectively, and the rates for patients who underwent endoaneurysmorrhaphy were 100%, 93.0%, 71.2%, respectively (P = .2). In the follow-up patient population, the mean preoperative EF was 40.21% +/- 9.44% in the classic aneurysmectomy group and 39.34% +/- 8.61% in the endoaneurysmorrhaphy group. Postoperatively, mean EFs increased to 44.24% +/- 9.50% and 43.80% +/- 8.81%, respectively, at the last follow-up. NYHA functional class changed from 2.79 +/- 0.77 preoperatively to 1.60 +/- 0.73 postoperatively in the classic aneurysmectomy group and from 2.97 +/- 0.71 preoperatively to 1.34 +/- 0.54 postoperatively in the endoaneurysmorrhaphy group. There was no significant difference in hospital readmissions for cardiac causes (classic, 27.1%; endoaneurysmorrhaphy, 31.2%). CONCLUSION: LV aneurysm can be repaired with acceptable surgical risk. Surgical treatment of LV aneurysm is associated with an improvement in long-term survival and symptoms.

Heart transplantation.

End-stage heart failure is still associated with a decrease in both quality and prognosis of life and one- year survival of these patients is below 50%. Heart transplantation remains the final therapeutic option for the treatment of irreversible end-stage heart failure in all age groups with adequate success rates. Survival of patients who underwent heart transplantation has improved incrementally in recent years, with 86% survival in the first year and over 50% survival at 10 years. Approximately 50% of patients live for more than 10 years after heart transplantation and 25% of patients live for more than 18 years. Improvement of the quality of life is an other benefit, while the patients were in NYHA class III-IV preoperatively, nearly all of them have an improved functional status with NYHA class I-II after transplantation. However, discrepancy between the number of candidates and number of available donors is still the major problem for the applicability of heart transplantation.

The effect of pentoxifylline on haemolysis during cardiopulmonary bypass in open-heart surgery.

OBJECTIVE: Haemolysis has long been recognized as one of the responses to cardiopulmonary bypass (CPB). Pentoxifylline (PTX), a methylxanthine derivative, has been known for many years for its haemorrheological properties. In this prospective, randomized study, we investigated whether a PTX treatment would reduce the haemolysis during CPB. METHODS: The effect of PTX treatment on haemolysis during CPB was studied in 25 patients (PTX group). Oral PTX (1200 mg/day in 3 divided doses) treatment for 3 days was followed by 300 mg i.v. PTX administration after anaesthesia induction. The control group consisted of 25 patients with equivalent surgery but no PTX treatment. Blood samples were collected at seven time points: prior to CPB, at 5 and 10 min of CPB and 5, 10 and 15 min after removal of cross clamping and 10 min after weaning from bypass in order to measure the haemolysis parameters, which included free haemoglobin and haptoglobin. RESULTS: PTX-treatment caused statistically significant decrements in plasma free haemoglobin levels during CPB. On the other hand, plasma haptoglobin levels stayed higher in PTX-medicated patients during the CPB as compared to control subjects. CONCLUSIONS: These findings suggested that PTX may be an effective agent in reducing the haemolysis during CPB.

A functional and histopathological comparison of proximal and distal saphenous vein contractility and morphology.

Variations in vascular reactivity and morphology of proximal and distal saphenous vein might affect its performance as a bypass conduit. Because peri- or postoperative graft spasm or intimal hyperplasia reduces patency, we compared the reactivity and morphology of human proximal and distal saphenous vein conduits. Isometric tension studies were performed in response to potassium chloride (80 mM), phenylephrine (10(-8) - 10(-5) M), norepinephrine (10(-8) - 10(-5) M), and angiotensin II (10(-11) - 10(-7) M). Relaxant responses were tested with acetylcholine (10(-9) - 10(-5) M), sodium nitroprusside (10(-10) - 10(-6) M), and diltiazem (10(-10) - 10(-4) M). Also, vein segments from proximal and distal leg saphenous vein grafts were collected for histopathologic investigation. In proximal and distal saphenous vein segments, we also examined the structure of intima, media, and adventitia, and we evaluated the smooth muscle cell/extracellular matrix ratio in the media. There was no significant difference (P > 0.05) between proximal and distal venous segments in response to vasoconstrictors or vasodilators. Similarly, investigation by light microscopy was unable to show any significant difference between proximal and distal conduits in vascular structure. The smooth muscle cell/extracellular matrix ratio was also similar in these graft materials. Our failure to find functional or morphologic differences between proximal and distal saphenous vein segments suggests that there is no advantage in using one of these preparations over the other as a conduit in coronary artery bypass operations.

A modified infarct exclusion technique for repair of anteroapical postinfarction ventricular septal defect.

Ventricular septal defects complicate approximately 1% to 2% of cases of acute myocardial infarction. Such postinfarction defects require urgent surgical treatment because, on medical treatment alone, 60% to 70% of patients die within the first 2 weeks. Despite the development of various surgical techniques for repair of postinfarction ventricular septal defect, the condition carries a high risk of recurrence and subsequent death. We describe a modification of the infarct exclusion technique in which the septal portion of the patch is reinforced by the right ventricular free wall. This modification appears to prevent leaks to the right ventricle through the ventricular septal defect, from anywhere around the patch. We applied this modified technique to 4 patients with anteroapical postinfarction ventricular septal defect. There was 1 early death, due to mesenteric artery occlusion secondary to embolus. No residual shunt was found during the postoperative period. We believe that our modification to the infarct exclusion technique might reduce both operative mortality and recurrence, by supporting friable endocardial tissue with right ventricular wall. We suggest that it be considered for use in patients with anteroapical ventricular septal defect and no severe right ventricular dysfunction.

The effect of pentoxifylline on haemolysis in patients with double cardiac prosthetic valves.

OBJECTIVE: Intravascular haemolysis frequently occurs in patients with mechanical heart valve prostheses. In this prospective study, we investigated whether pentoxifylline (PTX) has an effect on haemolysis following prosthetic valvular replacement in 40 patients who underwent double valve (mitral and aortic) replacement. METHODS AND RESULTS: The patients were randomly assigned to two groups as control (n = 20) and PTX group (n = 20). PTX was given in a daily oral dose of 1200 mg (3 times 400 mg) for 120 days. Laboratory tests for evidence of haemolysis namely, haemoglobin (Hb), haematocrit (Hct), plasma total bilirubin, indirect bilirubin and haptoglobin levels, corrected reticulocyte percent and serum lactic dehydrogenase activity (SLDH) were performed before and after the PTX treatment. PTX treatment caused significant increases in Hb, Htc, and haptoglobin levels (P < 0.05, P < 0.05 and P < 0.01, respectively). Additionally, there were significant decreases in SLDH, total and indirect bilirubin levels, and corrected reticulocyte percent in patients receiving PTX as compared with their respective control values (P < 0.01, for all). PTX treatment caused a significant improvement, to different extents, in signs of haemolysis in 60% of the patients. On the other hand, the response rate was 5% in the placebo-treated control group (P < 0.05). CONCLUSIONS: These findings suggest that PTX may be an effective agent in the management of haemolysis in patients with prosthetic heart valves.

The inhibitory action of protamine on human internal thoracic artery contractions: the effect of free hemoglobin.

OBJECTIVE: We investigated the mechanism of the protamine action and the effects of free hemoglobin on protamine-induced responses in endothelium-denuded and-intact human internal thoracic artery (ITA) rings precontracted with phenylephrine (PE) or high KCl. METHODS: Samples of redundant ITA obtained from patients undergoing a coronary artery bypass graft surgery were cut into 3 mm wide rings and suspended in 20 ml organ baths. Isometric tension was continuously measured with an isometric force transducer connected to a computer-based data acquisition system. RESULTS: Acetylcholine (Ach, 10(-8)-10(-5) M) caused a concentration-dependent relaxation of PE-precontracted ITA rings. Free hemoglobin (0.1 and 0.5 microM) produced a concentration-dependent and significant decrease in sensitivity (pD(2)) and maximal contractility (E(max)) in response to Ach in PE-precontracted ITA rings (P<0.0001). Protamine (50-800 microg/ml), free hemoglobin (0.1 and 0.5 microM), nitric oxide (NO) blocker N(omega)-nitro-L-arginine methyl ester (L-NAME, 100 microM) or soluble guanylate cyclase inhibitor methylene blue (10 microM) administration did not cause a significant alteration on basal tonus of endothelium-intact or -denuded ITA rings. Protamine (50-800 microg/ml) induced concentration-dependent relaxation responses in ITA rings precontracted by either PE or high KCl. There was no difference in sensitivity or maximal response to protamine between the endothelium-intact and -denuded rings. Incubation of endothelium-intact or -denuded ITA rings with L-NAME or free hemoglobin or methylene blue did not cause a significant inhibition on relaxation responses to protamine. ITA ring contractions induced by stepwise addition of calcium to high KCl solution with no calcium were almost completely inhibited by protamine (P<0.0001). CONCLUSIONS: It was suggested that protamine induced relaxation responses in human ITA rings is not NO- or endothelium-dependent but seems to depend on the interactions of protamine with calcium influxes and/or calcium release from intracellular stores in this tissue.

Aorta-right atrial tunnel.

Aorta-right atrial tunnel is rare. We report a case of aorta-right atrial tunnel in which the right coronary artery arose from the tunnel. Successful surgical treatment was performed.