LVAD therapy as a catalyst to heart failure remission and myocardial recovery.

The management of chronic heart failure over the past decade has witnessed tremendous strides in medical optimization and device therapy including the use of left ventricular assist devices (LVAD). What we once thought of as irreversible damage to the myocardium is now demonstrating signs of reverse remodeling and recovery. Myocardial recovery on the structural, molecular, and hemodynamic level is necessary for sufficient recovery to withstand explant and achieve sustained recovery post-LVAD. Guideline-directed medical therapy and unloading have been shown to aid in recovery with the potential to successfully explant the LVAD. This review will summarize medical optimization, assessment for recovery, explant methodologies and outcomes post-recovery with explant of durable LVAD.

Challenges for Emergent Combined Cesarean Delivery and Type A Aortic Dissection Repair Including Bleeding Management in the Setting of Full Heparinization: A Case Report.

Type A aortic dissection is rare in young females; however, it is associated with a high mortality rate. This case report describes a 30-year-old female at 38 weeks of gestation who presented with acute onset chest pain and hypotension responsive to intravenous fluid therapy. Transthoracic echocardiogram and chest computed tomography angiography confirmed a type A aortic dissection. The patient was transported urgently to the operating room for a Cesarean section and aortic dissection repair. Following induction of general anesthesia, the baby was delivered, oxytocin infusion was started, and a Bakri balloon was placed in the uterus. On cardiopulmonary bypass with circulatory arrest, the ascending aorta and aortic valve were repaired. Multiple uterotonic agents were required intraoperatively to manage persistent uterine bleeding in the setting of full heparinization. Both mother and baby survived without major complications. Preoperative management should focus on maternal hemodynamic control while completing a diagnostic evaluation. Intraoperative considerations include minimizing fetal exposure to medication, maintaining hemodynamic stability, and managing intraoperative blood loss in the setting of full anticoagulation.

Venoarterial extracorporeal membrane oxygenation is a viable option as a bridge to heart transplant.

OBJECTIVE: Venoarterial extracorporeal membrane oxygenation is a rescue therapy for patients in cardiogenic shock. We hypothesize that patients bridged to heart transplant with extracorporeal membrane oxygenation have decreased survival. METHODS: The United Network of Organ Sharing database was retrospectively reviewed from January 1, 1999, to March 31, 2018, for heart transplant recipients. Recipients bridged with any form of mechanical support and those without support were compared with recipients bridged with extracorporeal membrane oxygenation. The primary end point was restricted mean survival time through 16.7 years. RESULTS: Of 26,918 recipients, 15,076 required no pretransplant mechanical support (56.0%). Support patients included 9321 with left ventricular assist devices (34.6%), 53 with right ventricular assist devices (0.2%), 258 with total artificial hearts (1.0%), 686 with biventricular assist devices (2.6%), 1378 with intra-aortic balloon pumps (5.1%), and 146 who required extracorporeal membrane oxygenation (0.5%). In the first 16.7 years post-transplant, compared with recipients bridged with extracorporeal membrane oxygenation, estimated adjusted restricted mean survival time was higher in patients who required no mechanical support (16.6 months [14.0-19.4]) and patients with a left ventricular assist device (16.5 months [99% confidence interval, 13.9-19.2]), an intra-aortic balloon pump (11.2 months [8.3-14.7]), or a biventricular assist device (6.6 months [3.6-10.3]). Restricted mean survival time in patients with a right ventricular assist device or a total artificial heart was similar to patients with extracorporeal membrane oxygenation. CONCLUSIONS: Recipients bridged with extracorporeal membrane oxygenation were estimated to survive 16.6 months less than nonmechanical circulatory support recipients. Bridge to heart transplant with extracorporeal membrane oxygenation is a viable option, and these patients should be considered transplant candidates.

Repair of iatrogenic tracheal injury in acute respiratory failure with veno-venous extracorporeal membrane oxygenation.

Iatrogenic tracheal injuries are rare but potentially serious complications of endotracheal intubation that frequently require lung isolation to repair. This is not tolerated in patients with severe respiratory failure. We describe a case in a patient with acute respiratory distress syndrome, repaired using veno-venous extracorporeal membrane oxygenation.

The First Repair of Cor Triatriatum.

This article describes the first patient treated surgically for cor triatriatum, and also describes preoperative testing, operative findings, and procedures, as well as follow-up.