Association between pulmonary artery pulsatility and mortality after implantation of left ventricular assist device.

AIMS: Right ventricular failure after left ventricular assist device (LVAD) implantation is a major concern that remains challenging to predict. We sought to investigate the relationship between preoperative pulmonary artery pulsatility index (PAPi) and mortality after LVAD implantation. METHODS AND RESULTS: A retrospective analysis of the ASSIST-ICD multicentre registry allowed the assessment of PAPi before LVAD according to the formula [(systolic pulmonary artery pressure - diastolic pulmonary artery pressure)/central venous pressure]. The primary endpoint was survival at 3 months, according to the threshold value of PAPi determined by the receiver operating characteristic (ROC) curve. A multivariate analysis including demographic, echographic, haemodynamic, and biological variables was performed to identify predictive factors for 2 year mortality. One hundred seventeen patients were included from 2007 to 2021. The mean age was 58.45 years (±13.16), with 15.4% of women (sex ratio 5.5). A total of 53.4% were implanted as bridge to transplant and 43.1% as destination therapy. Post-operative right ventricular failure was observed in 57 patients (48.7%), with no significant difference between survivors and non-survivors at 1 month (odds ratio 1.59, P = 0.30). The median PAPi for the whole study population was 2.83 [interquartile range 1.63-4.69]. The threshold value of PAPi determined by the ROC curve was 2.84. Patients with PAPi ≥ 2.84 had a higher survival rate at 3 months [PAPi < 2.84: 58.1% [46.3-72.8%] vs. PAPi ≥ 2.84: 89.1% [81.1-97.7%], hazard ratio (HR) 0.08 [0.02-0.28], P < 0.01], with no significant difference after 3 months (HR 0.67 [0.17-2.67], P = 0.57). Other predictors of 2 year mortality were systemic hypertension (HR 4.22 [1.49-11.97], P < 0.01) and diabetes mellitus (HR 4.90 [1.83-13.14], P < 0.01). LVAD implantation as bridge to transplant (HR 0.18 [0.04-0.74], P = 0.02) and heart transplantation (HR 0.02 [0.00-0.18], P < 0.01) were associated with a higher survival rate at 2 years. CONCLUSIONS: Preoperative PAPi < 2.84 was associated with a higher risk of early mortality after LVAD implantation without impacting 2 year outcomes among survivors.

Percutaneous closure of an acquired and iatrogenic left ventricular-right atrium communication (Gerbode defect) with an Amplatzer Vascular Plug II.

Gerbode defect is defined as an abnormal left ventricle-right atrium shunting which may have congenital or acquired origin, first described by Thurman in 1838, representing 0.08% of intracardiac shunts and <1% of the congenital heart diseases. The acquired defect can be classified as iatrogenic or non-iatrogenic, with previous cardiac surgery being the most common cause. Gerbode defect is classified depending on its position with respect to the tricuspid valve in supravalvular, infravalvular, or intermediate. Our purpose was to report a rare case of an iatrogenic and acquired Gerbode defect in a 10-year-old male patient following surgical correction of a partial anomalous pulmonary venous return of the right pulmonary veins to the right atrium. The defect was successfully closed percutaneously with an Amplatzer™ Vascular Plug II device. Percutaneous closure of acquired Gerbode defects could be considered as a good option using soft devices to reduce the possibility of severe complications such as complete heart block due to the location of the defect. .

[Disorders of heart structure and function parameters and hepatolienal blood flow remodeling in patients with virus-induced cirrhosis].

AIM: To study heart structure and function parameters and hepatolienal blood flow in patients with virus-induced cirrhosis (VIC). MATERIALS AND METHODS: 95 patients with VIC (mean age, 38.6; disease duration, 4.5 years) were evaluated. Doppler EchoCG and Doppler ultrasonic examination of hepatolienal vasculature (VIVID E 95 apparatus) were performed. The control group consisted of 19 healthy individuals. Statistical analysis was performed using the Statistica 6.0 software. RESULTS: The study of hepatolienal blood flow showed that the splanchnic artery blood flow velocity was increased by 25%, the hepatic vein blood flow velocity was increased by 13%, and splanchnic arteries and veins were dilated. 24% of VIC patients had moderate pulmonary hypertension associated with a 20% dilatation of inferior vena cava (p=0.007), a 28% increase in hepatic vein blood flow velocity (p=0.0003), and a 13% decrease in portal vein diameter (p=0.001). Four types of left ventricular (LV) geometry were identified: 40% of VIC patients had normal geometry; 17% of patients had concentric hypertrophy; 23% of patients had concentric remodeling; and 19% had eccentric hypertrophy. Features of hepatolienal blood flow were related with the LV geometry type. LV diastolic filling was impaired in 44.3% and RV diastolic filling - in 33% of patients. In patients with VIC, the disturbed diastolic function was associated with 25% reduced hepatic vein blood flow velocity (p=0.05) whereas development of RV diastolic dysfunction was associated with 6% reduced portal vein diameter (p=0.04), 17% dilated portal vein (p=0.006), and 25% decreased portal vein blood flow velocity (p=0.001). Anti-viral therapy resulted in improvement of some hepatolienal blood flow parameters. Parameters of splanchnic circulation were correlated with cardiodynamic parameters with correlation coefficients from 0.51 to 0.95 at p.

Coronary-Cameral Fistula Caused by Guidewire Trauma and Resolved by Coil Embolization.

A 57-year-old woman presented with effort angina. A coronary angiogram revealed critical 2-vessel disease, for which she subsequently underwent percutaneous coronary intervention. During angioplasty, a coronary guidewire-inadvertently passed into the right ventricle through the septal branches of the posterior descending coronary artery-caused a coronary artery-to-right ventricular fistula. This fistula was successfully closed percutaneously by coil embolization. To our knowledge, this is the first report of a case in which a coronary artery-to-right ventricular fistula caused by a guidewire was managed successfully by coil embolization.

Model for end-stage liver disease predicts right ventricular failure in patients with left ventricular assist devices.

High rates of right ventricular failure continue to affect postoperative outcomes in patients implanted with left ventricular assist devices (LVADs). Development of right ventricular failure and implantation with right ventricular assist devices is known to be associated with significantly increased mortality. The model for end-stage liver disease (MELD) score is an effective means of evaluating liver dysfunction. We investigated the prognostic utility of postoperative MELD on post-LVAD implantation outcomes. MELD scores, demographic data, and outcomes including length of stay, survival, and postoperative right ventricular failure were collected for 256 patients implanted with continuous flow LVADs. Regression and Kaplan-Meier analyses were used to investigate the relationship between MELD and all outcomes. Increased MELD score was found to be an independent predictor of both right heart failure and necessity for RVAD implantation (OR 1.097, CI 1.040-1.158, p = 0.001; OR 1.121, CI 1.015, p = 0.024, respectively). Patients with RV failure and who underwent RVAD implantation had reduced postoperative survival compared to patients with RV dysfunction (no RV failure = 651.4 ± 609.8 days, RV failure = 392.6 ± 444.8 days, RVAD = 89.3 ± 72.8 days; p < 0.001). In conclusion, MELD can be used to reliably predict postoperative right heart failure and the necessity for RVAD implantation. Those patients with RV failure and RVADs experience significantly increased postoperative mortality compared to those without RV dysfunction.

Da Silva's cone repair for Ebstein's anomaly: effect on right ventricular size and function.

OBJECTIVES: Da Silva's cone repair is a novel technique for surgical reconstruction of the tricuspid valve and the right ventricle (RV) in Ebstein's anomaly. The technique consists of extensive leaflet mobilization, longitudinal plication of the atrialized ventricle and cone-shaped reconstruction of the tricuspid valve, allowing for leaflet-to-leaflet coaptation. We evaluated the influence of Da Silva's cone repair on tricuspid competency, right ventricular size and function. METHODS: From February 2010 until July 2013, 20 patients (median age 30.0 years, range 6.6-68.3 years) underwent Da Silva's cone repair. A 4- to 6-mm interatrial communication was left in all patients. Echocardiographic studies and magnetic resonance imaging (MRI) before and after the repair were evaluated. RESULTS: Median follow-up was 11 (0.5-36) months. There were 2 early deaths and no late death. Echocardiography at follow-up revealed mild or absent tricuspid regurgitation in 16 patients. Two patients showed moderate tricuspid insufficiency. MRI studies showed that the mean functional RV end-diastolic volume decreased after surgery (pre 334 [135-656] ml; post 175 [115-404] ml, P < 0.001). The mean RV ejection fraction decreased (pre 47 ± 10%; post 35 ± 13%, P = 0.001), and the mean antegrade net stroke volume of the RV increased (pre 65 ± 28 ml; post 75 ± 30 ml, P = 0.057). CONCLUSIONS: Da Silva's cone repair for Ebstein's anomaly creates excellent valve function in all patients. Consecutively, the size of the RV decreases and the antegrade net stroke volume increases 6 months after the operation.

Ventricular septal defect and bidirectional shunting? Things are not what they seem.

This report describes the case of a 19-year-old woman with a diagnosis of muscular ventricular septal defect. Bidirectional shunting was observed during a transthorathic echocardiography evaluation which also suggested normal pulmonary arterial pressure. Moreover, anomalous and hypertrophic right ventricular muscular bands were observed. After having ruled out other possibilities, the plausible explanation is one, which is not described in the literature. The findings may be explained as a sequestrated portion of the cavity of the right ventricle that remains isolated from the rest of the right ventricle (RV) by anomalous and hypertrophic right ventricular muscular bands, with communication only between the left ventricle and the sequestrated part of the RV. This is an unusual variant of two-chambered RV simulating two-chambered left ventricle.

Congenitally Corrected Transposition of Great Arteries: Surgical Options for the Failing Right Ventricle and/or Severe Tricuspid Regurgitation.

In patients with congenitally corrected transposition of the great arteries, the main concern has been the long-term performance of the morphologic right ventricle in association with tricuspid valve regurgitation when it remains as the systemic ventricle. Deterioration in ventricular function can occur slowly over many years, even without associated cardiac anomalies or previous surgical interventions. This review summarizes the authors' experience and provides a thorough review of the literature addressing the management of the failing systemic right ventricle as well as the tricuspid valve regurgitation with congenitally corrected transposition. This includes different surgical options, the authors' preferred management algorithm, and the late outcome.