Metabolomics profiling for diagnosis of acute renal failure after cardiopulmonary bypass.

RATIONALE: Acute renal failure (ARF) is one of the most serious complications of cardiopulmonary bypass (CPB) surgery. Serum creatinine level is a key compound examined to understand whether renal function is normal. However, its level may vary based on age, gender, race, muscle mass, nutrition, and drugs taken by an individual. In addition, it may not be detected without a 50% reduction in renal function and may lead to delays in treatment. New markers are needed for early diagnosis of ARF. They were determined for early diagnosis of ARF after CPB. Metabolic differences in plasma samples of individuals who developed and did not develop ARF after cardiopulmonary bypass were determined. METHODS: This study was the first to perform an untargeted metabolomics analysis for early diagnosis of ARF after CPB surgery. Plasma samples were taken from 105 patients (9 ARF patients) at five time points to identify the time at which a more accurate ARF diagnosis can be made. A total of 687 samples, including quality control samples, were analyzed. RESULTS: Two hundred twenty-six metabolites were identified using retention index libraries. Based on the statistical evaluations, tryptophan, threonine, and methionine were found in lower concentrations in patients with ARF compared to the control group at all time points. Whereas gluconic acid, hypoxanthine, and lactic acid showed a decreasing trend over time, longitudinal analysis showed that cysteine, hippuric acid, and uric acid levels increased over time in the ARF group. CONCLUSIONS: These metabolites are candidate biomarkers for early diagnosis of ARF as well as biomarkers for tracking the recovery of ARF patients.

Implantation of a fully magnetically levitated left ventricular assist device to a 3-year-old patient with body surface area of 0.57 m2.

Postoperative 3D thorax computed tomographic scan image of the patient.

Should we touch tricuspid valve at the time of LVAD implantation? A young patient series.

BACKGROUND: The aim of the study is to compare the results of patients who had moderate or severe tricuspid insufficiency (TI) at the time of left ventricular assist device (LVAD) implantation that did not undergo intervention. METHODS: Between October 2013 and December 2019, 144 patients who did not undergo tricuspid valve repair (TVR) during LVAD implantation in our department were included in the study. The patients were divided into two groups according to the TI grade; Group 1: 106 patients (73.6%) with moderate TI and Group 2: 38 patients (26.4%) with severe TI. All patients were evaluated for mortality, need of inotrope, blood product transfusion, intensive care unit (ICU) stay, duration of mechanical ventilation, and early and late right ventricular failure (RVF). Minimally invasive technique was favored in patients with worse right ventricular (RV) function to prevent the need for postoperative RV support and bleeding. RESULTS: The mean ages of the patients in the Group 1 and Group 2 were 46 ± 15 years (82% male), and 45 ± 11.2 years (81.5% males), respectively. Post-operative duration of mechanical ventilation, ICU stay, blood loss, and reoperations were similar (p > 0.05). There was no significant difference in early RVF, pump thrombosis, stroke, bleeding, and 30-day mortality between groups (p > 0.05). Incidence of late RVF was higher in Group 2 (p < 0.05). CONCLUSION: Although the risk of late RVF may increase in patients with preoperative severe TI, not intervening in TI during LVAD implantation does not cause adverse clinical outcomes in the early period.

Adaptation of adult right ventricular scoring systems to pediatric patients undergoing continuous LVAD implantation: Feasible or not?

PURPOSE: The aim of this study is to investigate the efficacy of adaptation of right ventricular (RV) risk scores used in adult patients to pediatric age group undergoing LVAD implantation. METHODS: Twenty-two pediatric patients who underwent LVAD implantation were retrospectively reviewed from January 2014 to September 2018. Preoperative patient characteristics, hemodynamic parameters, and echocardiographic data were collected. Adult RV risk scores were calculated for all patients. Effects of all the parameters on RV function were also investigated. Study endpoints were RVF and in-hospital mortality. RESULTS: Eleven (50%) of 22 patients were male. The mean age of the patients was 13.4 ± 3.8 years. The mean body surface area of the patients was 1.4 ± 0.4 m2. In five patients BiVAD implantation was performed. Of these five BiVAD patients two underwent successful heart transplant; two weaned from temporary RVAD and last patient died due to multi-organ failure. Four patients showed signs of early RVF; one patient was transplanted successfully while on medical support. Three patients developing RVF did not respond medical therapy necessitating ECMO and died in the early postoperative period. All risk scores and potential predictive factors were evaluated individually and in combination of several parameters. No significant predictor for RVF in pediatric patients that underwent LVAD implantation was found (p > 0.05). CONCLUSION: Neither an adult risk score nor a predictive factor was successful in predicting RVF, alone or in combination due to limited number of patients and events. Large further investigations are needed to identify the predictors or scoring system in pediatric population.

Off-pump implantation of left ventricular assist device via minimally invasive left thoracotomy: Our single-center experience.

Background: The aim of this study was to compare our experience of left ventricular assist device implantation via minimally invasive left thoracotomy with off-pump versus on-pump technique. Methods: Between June 2013 and April 2020, nine patients (8 males, 1 female; mean age: 47±11.9 years; range, 30 to 61 years) who underwent off-pump left ventricular assist device implantation and nine patients (8 males, 1 female; mean age: 47±11.4 years; range, 29 to 60 years) who underwent on-pump minimally invasive left thoracotomy were retrospectively analyzed. Postoperative outcomes and mid-term results of both groups were evaluated. Results: Outflow graft was anastomosed to the ascending aorta with J-sternotomy in all patients. The median duration of intubation and intensive care unit stay were one (IQR: 1.5) day and eight (IQR: 6.5) days in the off-pump group, respectively and one (IQR: 0) day and seven (IQR: 7) days in the on-pump group, respectively. Intra-aortic balloon pump was needed during the weaning of cardiopulmonary bypass in one (11%) of the patients in both groups. Postoperative right ventricular failure was observed in two (22%) patients in the offpump group who were treated medically and recovered. There was no need for revision due to bleeding or postoperative extracorporeal membrane oxygenator implantation in either group. In the off-pump group, three patients underwent heart transplantation after median 854 (IQR: 960) days. Three patients died one month, two and four years after implantation. Three patients were still alive with left ventricular assist device and were being uneventfully followed for 365, 400, and 700 days after implantation. Conclusion: Off-pump technique is safe and feasible option for implantation of left ventricular assist device via minimally invasive left thoracotomy.

CoronaVac, BNT162b2 and heterologous COVID-19 vaccine outcomes in patients with ventricular assist device.

BACKGROUND: A consensus has not yet been reached regarding which COVID-19 vaccine program should be applied in patients with ventricular assist device (VAD). Our aim was to assess the clinical outcome of inactivated, mRNA and heterologous vaccine program in patient with VAD. METHODS: In this retrospective and cross-sectional study; adult patients who underwent VAD implantation between January 2012 and September 2021 and received any vaccine that were used in Republic of Türkiye for COVID-19, were included. The patients were divided into three groups according to the type of vaccine; "inactivated," "mRNA" and "heterologous." Clinical outcomes were analyzed. RESULTS: Eighteen patients were in each group in the "inactivated," "mRNA" and "heterologous" groups. Mean age was 51.6 ± 12 years in "inactivated" group, 42.5 ± 15.5 years in "mRNA" group and 41.1 ± 15.4 years in "heterologous" group. There was no significant difference between the groups in age, gender, body surface area, body mass index and etiology (p > 0.05). After last dose of vaccines, the number of patients had COVID-19 positive test were three (16.7%), one (5.6%), and two (11.1%) in "inactivated," "mRNA" and "heterologous" groups, respectively. Pump thrombosis was seen in two patients in "mRNA" group and one patient in "heterologous" group. No pump thrombosis was seen in "inactivated" group. COVID-19-related death or intubation was not observed. CONCLUSION: All vaccine that used for COVID-19 are safe and effective in patients with VAD. In countries that give priority to inactivated vaccines, mRNA vaccines may then be made as boosters.

Stereotactic body radioablation therapy as an immediate and early term antiarrhythmic palliative therapeutic choice in patients with refractory ventricular tachycardia.

BACKGROUND: Stereotactic body radioablation therapy (SBRT) has recently been introduced with the ability to provide ablative energy noninvasively to arrhythmogenic substrate while reducing damage to normal cardiac tissue nearby and minimizing patients' procedural risk. There is still debate regarding whether SBRT has a predominant effect in the early or late period after the procedure. We sought to assess the time course of SBRT's efficacy as well as the value of using a blanking period following a SBRT session. METHODS: Eight patients (mean age 58 ± 14 years) underwent eight SBRT sessions for refractory ventricular tachycardia (VT). SBRT was given using a linear accelerator device with a total dose of 25 Gy to the targeted area. RESULTS: During a median follow-up of 8 months, all patients demonstrated VT recurrences; however, implantable cardioverter-defibrillator (ICD) and anti-tachycardia pacing therapies were significantly reduced with SBRT (8.46 to 0.83/per month, p = 0.047; 18.50 to 3.29/per month, p = 0.036, respectively). While analyzing the temporal SBRT outcomes, the 2 weeks to 3 months period demonstrated the most favorable outcomes. After 6 months, one patient was ICD therapy-free and the remaining patients demonstrated VT episodes. CONCLUSIONS: Our findings showed that the SBRT was associated with a marked reduction in the burden of VT and ICD interventions especially during first 3 months. Although SBRT does not seem to succeed complete termination of VT in long-term period, our findings support the strategy that SBRT can be utilized for immediate antiarrhythmic palliation in critically ill patients with otherwise untreatable refractory VT and electrical storm.

A rare case of intracardiac leiomyomatosis in a patient who underwent complete tumor resection only using the laparotomic approach.

Intracardiac leiomyomatosis (ICLM) is a rare tumor that usually originates from the mesenchymal cells of the uterus. If left untreated, it may lead to cardiac symptoms and sudden death. The present case was a 45-year-old female patient who presented with occasional palpitations. The imaging methods revealed a heterogeneous mass likely to be leiomyoma with intense enhancement in the arterial phase in the uterus, extending from the ovarian and uterine veins to the heart through the inferior vena cava. The tumor council attributed these findings to intravenous leiomyomatosis with intracardiac extension. Accordingly, a multidisciplinary surgical team performed complete excision of the intracardiac leiomyomatosis in the patient presented herein using only the laparotomic approach. The gold standard in the treatment of ICLM is complete tumor excision. Excision of intracardiac tumors can be performed through controlled traction from the abdominal region.

Relationship Between Preoperative NT-proBNP and Postoperative Adverse Events in Patients with Left Ventricular Assist Device.

BACKGROUND: The aim of this study is to investigate the relationship of preoperative NT-proBNP values with postoperative adverse events in patient left ventricular assist device (LVAD) implantation. METHOD: Forty-six patients (35 males; mean age 49.4 ± 12.9 years) who underwent LVAD implantation between 2016 and 2018 were evaluated in this study. The analysis was made on the relationship between preoperative NT-proBNP and mortality, postoperative right ventricular failure (RVF), postoperative drainage, duration of intubation, and intensive care unit stay, was examined. The optimal NT-proBNP cut-off values for predicting mortality were determined using Receiver Operator Characteristic (ROC) curve analysis and the patients were divided into two groups according to the specified cut-off point. RESULT: Median NT-proBNP was higher in patients who died, had postoperative extracorporeal membrane oxygenation, and early RVF. The median NT-proBNP was 11,103 pg/ml in patients with IABP, and 2943 pg/ml in patients without IABP, and the difference was statistically significant (p = 0.002). The cut-off point for NT-proBNP was found to be 1725.5 pg/ml (Sensitivity:0.929, Specificity:0.688). Accordingly, when the patients were divided into two groups and analyzed, no statistically significant difference was found between preoperative NT-proBNP below or above 1725.5 and postoperative adverse events. There was no statistically significant correlation between preoperative NT-proBNP and postoperative drainage, duration of intubation time, and duration of ICU stay (p > 0.05). CONCLUSION: Routine monitoring of preoperative NT-proBNP and comparison with postoperative values are important in terms of patient selection, the timing of surgery, follow-up of postoperative adverse events, and improving outcomes in VAD patients.

Prolonged Extracorporeal Membrane Oxygenation Support as a Bridge to Heart Transplant.

Heart transplant is in high demand, but the wait list exceeds 6 months in Turkey. Until a donor heart can be procured, venoarterial extracorporeal membrane oxygenation is an important support option to bridge patients on the wait list or as a rescue therapy for patients with right ventricular failure after implant of left ventricular assist device; it is less expensive than other options, provides benefits such as simple percutaneous insertion, and requires neither sternotomy nor biventricular and respiratory support. We present a case of a patient bridged to transplant with 5 months of extracorporeal membrane oxygenation support.

Use of Stereotactic Radioablation Therapy as a Bailout Therapy for Refractory Ventricular Tachycardia in a Patient with a No-entry Left Ventricle.

In patients with mechanical aortic and mitral valves and left ventricular (LV) tachycardia (VT), catheter ablation is technically challenging due to the limited access to the LV. Promising new alternatives to radiofrequency ablation include pulsed-field electroporation, percutaneous or surgical sympathetic neuromodulation, and noninvasive stereotactic radioablation therapy (SBRT). We herein describe the effect of SBRT as a bailout therapy on the management of a challenging VT case in the presence of double left-sided mechanical valves.

Raising the bar to ultradisciplinary collaborations in management of chronic thromboembolic pulmonary hypertension.

Chronic thromboembolic pulmonary hypertension is an underdiagnosed and potentially fatal subgroup of pulmonary hypertension, if left untreated. Clinical signs include exertional dyspnea and non-specific symptoms. Diagnosis requires multimodality imaging and heart catheterization. Pulmonary endarterectomy, an open heart surgery, is the gold standard treatment of choice in selected patients in specialized centers. Targeted medical therapy and balloon pulmonary angioplasty can be effective in high-risk patients with significant comorbidities, distal pulmonary vascular obstructions, or recurrent/persistent pulmonary hypertension after pulmonary endarterectomy. Currently, there is a limited number of data regarding novel coronavirus-2019 infection in patients with chronic thromboembolic pulmonary hypertension and the changing spectrum of the disease during the pandemic. Challenging times during this outbreak due to healthcare crisis and relatively higher case-fatality rates require convergence; that is an ultradisciplinary collaboration, which crosses disciplinary and sectorial boundaries to develop integrated knowledge and new paradigms. Management strategies for the "new normal" such as virtual care, preparedness for further threats, redesigned standards and working conditions, reevaluation of specific recommendations, and online collaborations for optimal decisions for chronic thromboembolic pulmonary hypertension patients may change the poor outcomes.

Driveline exit-site care protocols in patients with left ventricular assist devices: a systematic review.

OBJECTIVES: Driveline infections continue to be a significant complication following left ventricular assist device (LVAD) implantation. Driveline exit-site care is crucial for the prevention of infections; however, there are no uniform guidelines. The goal of this study was to provide an overview of the currently published driveline exit-site care protocols in patients with LVAD. METHODS: A systematic literature review was performed. Studies before 15 December 2020 were included if the number of driveline infections was a primary outcome and the driveline exit-site care protocol was explained. RESULTS: Eleven articles were included in the systematic review, including 1602 patients with LVADs. The median of the frequency of driveline infections in the articles was 13.8% with a range of 0-52.6%. There was a marked variability in the methods of care of driveline exit sites, without a standardized driveline dressing technique in patients with LVADs. The frequency of driveline infections was 6-7.5% in studies using a dressing kit that included chlorhexidine, a silver-based dressing and an anchoring device. Furthermore, there was variability in the anchoring devices and the frequency of dressing changes, which varied from daily to weekly. No specific anchoring device or change frequency was found to be superior. CONCLUSIONS: Based on this systematic review, driveline exit care protocols that included chlorhexidine, a silver-based dressing, the use of an anchoring device and dressing kits might be best in reducing driveline infection rates. However, prospective studies with larger cohorts are needed to establish the optimal protocol for driveline exit-site care.

Does minimally invasive approach reduce risk of infection after ventricular assist device implantation?

BACKGROUND: We analyzed patients with left ventricular assist device (LVAD) related and specific infection, and aimed to determine whether surgical technique implantation affect the frequency of infection. METHODS: We retrospectively analyzed the data of 99 patients who received LVAD at our department between June 2013 and June 2019. Patients were divided into two groups according to the surgical technique. Group A (n = 58) was conventional sternotomy (CS) and group B (n = 41) was on-pump minimally invasive left thoracotomy (MILT). Demographics, preoperative risk factors, LVAD infections, surgical incision site, driveline site, and outcomes were compared between these two groups. RESULTS: Mean follow up time was 589 ± 480 (31-2171) days. Infection was detected in 34% (41/99) of LVAD patients. Admission to emergency department and intensive care unit (ICU) in last 6 months were significantly higher in MILT group. There was no difference between the two groups in terms of driveline exit site infection (CS: 28%, MILT: 27%) (p > 0.05). Seven (17%) patients had infection in the thoracotomy incision site area in the MILT group. The rate of ICU hospitalization in the last 6 months was seen as the only independent risk factor increasing the frequency of infection (R = 0.30; p = 0.016). Survival analysis at 60 days, 1 year and 2 years showed no difference between the two groups (p = 0.09). CONCLUSIONS: Despite advances in pump technology and surgical technique, infection is still an important cause of mortality and morbidity.

Midterm Results of Minimally Invasive Left Thoracotomy Fully Magnetically Levitated Left Ventricular Assist Device Implantation.

The aim of the study is to compare outcomes of the patients who underwent HeartMate3 (HM3) implantation with conventional sternotomy (CS) and minimally invasive thoracotomy technique (MILT). From June 2013 to April 2019, 50 patients who underwent isolated HM3 implantation were included. Patients were divided into two groups according to the operative technique; of 50 patients, 28 were implanted with CS and 22 with MILT. All patients were evaluated for mortality, need of inotrope, blood product transfusion, intensive care unit stay, time on mechanical ventilation, and postoperative right ventricular failure. Primary outcomes were early mortality and occurrence of adverse events. Patients characteristics were similar; preoperative central venous pressure (CVP) and the ratio of CVP to pulmonary capillary wedge pressure (CVP/PCWP) were significantly higher in the MILT group versus the CS group (p < 0.05). Intensive care unit stay was significantly shorter in the MILT group (p < 0.05). Incidence of bleeding requiring exploratory sternotomy and postoperative drainage on the first postoperative day were statistically higher in the CS group (p < 0.05). Right ventricular failure was higher in the CS group but was not statistically significant (p = 0.4). There was no significant difference in long-term adverse events. The Kaplan-Meier survival analysis showed no difference between the groups (p = 0.66). The HM3 assist system can be successfully implanted with the MILT technique, which has proved to be safe and reproducible and yields good clinical outcomes.

More continuous flow, better learning? The effect of aortic valve opening in patients with left ventricular assist device.

PURPOSE: The aim of this study was to analyze neurocognitive function in patients who underwent continuous flow left ventricular assist device (LVAD) implantation. MATERIAL AND METHOD: This cross-sectional study included three groups: LVAD (n = 31), heart failure patients (n = 26), and healthy volunteers (n = 27). The Rey Auditory-Verbal Learning Test (RAVLT), Judgement of Line Orientation Test (JLOT), Trail Making Test (TMT), Stroop Color-Word Interference Test (SCWIT), Verbal Fluency Test (VFT), Symbol-Digit Modality Test (SDMT) were used to assess the neurocognitive functions. Data were analyzed at a median 12 (3-47) months after LVAD implantation. The LVAD patients were also divided by aortic valve opening (AVO) into three subgroups as "closed" (n = 9), "1-6" (n = 8) and "7-10" (n = 14) opening per ten beats and data were re-analyzed accordingly. RESULTS: There was no significant difference among the groups according to SCWIT, JLOT, SDMT, TMT, and VFT scores. Post-hoc analyzes of RAVLT scores showed significant differences between the LVAD and the other two groups in favor of the LVAD group. Also, the patients with AVO "7-10" the response times were longer and learning scores were found to be lower than those without AVO. CONCLUSION: With continuous-flow LVAD, neurocognitive functions were not impaired. The learning performance was better in cases where there was no AVO and flow was completely device dependent. We may speculate that neurocognitive functions are not worsening with continuous cerebral blood flow and even it may improve learning performance.

A Stepwise Approach to Left Ventricular Assist Device Pump Thrombosis.

AIM: Pump thrombosis (PT) is a detrimental complication of left ventricular assist device (LVAD) therapy. There is no consensus on optimal PT treatment. The aim of this study was to present a treatment strategy for patients with PT. METHOD: The hospital records of patients who underwent isolated LVAD implantation between May 2013 and October 2018 were retrospectively evaluated. Pump thrombosis was suspected in the setting of impaired flow/power parameters and haemolysis. Protocols for the management of suspected PT varied by patient presentation. Parameters that increased the PT risk were investigated by dividing the patients into two groups according to the presence of PT. Preoperative and operative data were analysed. RESULTS: Pump thrombosis was observed in 20 of 81 patients. All patients with PT presented elevated lactate dehydrogenase levels and higher power and/or low-/high-flow alarm at admission. All patients were treated initially with intravenous unfractionated heparin infusion; three patients did not require further treatment, one patient died due to sudden cardiac arrest, and three patients underwent urgent surgery for LVAD exchange. Thirteen (13) patients received tissue plasminogen activator infusion; eight were discharged without any signs of thrombosis, and three were bridged to transplant. One (1) major bleeding event leading to death was observed. Freedom from second PT was found in 91% cases at 6 months and in 68.2% at 1 year. We found that a larger left ventricle and the type of pump determined the risk of PT. CONCLUSIONS: Low-dose thrombolytic therapy should be considered as a feasible treatment option for patients with PT.

Building a patient blood management program in a large-volume tertiary hospital setting: Problems and solutions.

Successful implementation of a patient blood management program necessitates the collaboration of a strong organization and a multidisciplinary approach. We organized a meeting with broad participation in our center to establish a consensus for implementation of a specific patient blood management program. International and domestic experiences were shared, the importance of coordination and execution of different pillars in patient blood management were discussed, and the problems about the blood transfusion system were also investigated with the proposal for solutions. The data obtained from this meeting are presented to be a guide for similar large-volume tertiary hospitals for integration of a patient blood management protocol.

International experience using a durable, centrifugal-flow ventricular assist device for biventricular support.

BACKGROUND: Heart transplantation is limited by the scarcity of suitable donors. Patients with advanced biventricular failure may require biventricular support to provide optimal cardiac output and end-organ perfusion. We highlight the outcomes of using the HeartWare HVAD System (HVAD) in a biventricular configuration. METHODS: This retrospective study included patients implanted with HVAD as a biventricular assist device (BiVAD) between 2009 and 2017 at 12 participating centers. When used as a right ventricular assist device (VAD) (RVAD), the HVAD can be attached to the right ventricle (RV) or the right atrium (RA). Kaplan-Meier survival estimates were calculated comparing the 2 RVAD implant locations. Comparisons were also made between the timing of RVAD implantation (primary vs staged) on adverse event (AE) profiles and survival. RESULTS: Among the 93 patients who were implanted with a HVAD BiVAD, Kaplan-Meier survivals at 1-year and 2-year were 56% and 47%, respectively. Survival was independent of the location of the HVAD RVAD implant or whether there was an interval between left VAD and RVAD implantation. The most common AEs were bleeding (35.5%), infection (25.8%), and respiratory failure (20.4%). CONCLUSIONS: This study illustrated similar survival in patients receiving a primary or staged HVAD BiVAD implant at 1 year and 2 years. This study also established that the locations of the RVAD implant (RV or RA) result in similar AE profiles.