Questionable Long-Term Results of the Extended Provisional Extension to Induce Complete Attachment (E-PETTICOAT) Technique in the Management of Chronic Type B Aortic Dissection.

BACKGROUND: Published interim results of the extended provisional extension to induce complete attachment (e-PETTICOAT) technique suggested favorable remodeling in chronic type B Aortic Dissection (cTBAD). This report presents long-term results of the e-PETTICOAT technique for the management of cTBAD (without aneurysmal dilatation). METHODS: Patients with cTBAD below the 55 mm aortic size were eligible for the management using the e-PETTICOAT technique. Follow-up was conducted at 1, 2 and 5 years based on the computed tomography angiogram. All the presurgery risk factors (entry >1 cm, inner curve entry, fusiform index >0.65, false lumen > 22 mm, aortic size >40 mm, recurrent pain or hypertension, and Stanford Dissection Risk Calculation) and postsurgery complications were examined in the study. RESULTS: A total of 20 patients underwent the e-PETTICOAT surgery. The survival rate at 1, 2, and 5 years was 75%, 70%, and 64%, respectively, and the percentage of patients without any reinterventions was 100%, 93%, and 18%. Aortic degeneration was recognized in 30%, 55%, and 85% of the patients. Only 3 of the 20 patients were alive and without any reintervention after 5 years. The receiver operating curve analysis does not indicate any factor that would predict the remodeling result in the long-term follow-up. CONCLUSIONS: The use of e-PETTICOAT technique in cTBAD might not have a beneficial influence on the long-term results.

Early detection of HVAD pump thrombosis based on technical analysis and power consumption measurements.

BACKGROUND: Continuous-flow left ventricular assist devices (LVADs) have been extensively used in a strategy of bridge to orthotopic heart transplant and destination therapy. The usage of LVAD, however, is not free from limitations such as device-related adverse events, including pump thrombosis (PT). We aimed to develop an algorithm of early PT detection based on the maintenance parameters monitored by the implanted device. METHODS: We analyzed log files of 101 patients implanted with HeartWare pump (HVAD) with 18 PT events among them. For signal processing, we used the open-high-low-close format transformation and typical price (TP) technical analysis indicator. Model parameters were tuned with 5-fold cross-validation, and the final performance was measured on a separate group of patients. RESULTS: Our algorithm achieved 100% sensitivity and 100% specificity of indications. In the final evaluation, alarms preceded the clinical acknowledgement of events by 2 days and 20 h on average. In the worst-case scenario, an alarm was raised 1 day and 8 h prior to the event. CONCLUSIONS: The proposed algorithm could be installed to work directly with the device controller and provide clinicians with automatic readings analysis, raising an alarm when there is a high probability of thromboembolism. Early event detection could enable better thrombosis management and improve prognosis in patients implanted with HVAD.

Initial experience with intracorporeal continuous ow LVAD in pediatric patients in Poland.

THE AIM: The aim of the study is to present the initial experience with continuous flow left ventricle assist device (CF-LVAD) in pediatric patients with BSA below 1.5 m2. MATERIAL AND METHODS: Between 2016 and 2017, CF-LVAD (the Heartware System) have been implanted in three pediatric patients in the Department of Pediatric Cardiac Surgery, Jagiellonian University, Krakow, Poland. The indications for initiating CF-LVAD were end-stage congestive heart failure due to dilated cardiomyopathy in all children. RESULTS: Implanted patients have had BSA of 1.09, 1.42, 1.2 m2, and 37, 34, 34 kg of body weight and the age 12, 11, 12 years, respectively. The time of support was 550 days in two patients and 127 in another one, and is ongoing. The main complication has been driveline infection. CONCLUSION: The outcomes from our single-center experience using the HeartWare CF-LVAD have been excellent with a low incidence of complication and no necessity to reoperation in our patients. Children could be successfully and safely discharged home.

Activated Hemostatic Biomarkers in Patients with Implanted Left Ventricle Assist Devices: Are Heparin and/or Clopidogrel Justified?

BACKGROUND: Adequate anticoagulation represents a major problem for left ventricle assist device (LVAD) utilization in patients awaiting heart transplantation as well as for regeneration of the native heart. The proper management of hemostatic abnormalities during LVAD support may improve survival by reducing the incidence of hemorrhagic and/or thromboembolic complications. CASE REPORT: A 40-year-old man with implanted pulsatile LVAD due to dilated cardiomyopathy received aspirin and warfarin. The patient underwent serial weekly monitoring of hemostatic biomarkers including international normalization ratio, prothrombin time, prothrombin activity, activated partial thromboplastin time, fibrinogen, D-dimer, platelet aggregation induced by adenosine diphosphate and arachidonic acid, platelet count, and mean platelet volume. The external pump was exchanged three times - twice because of a clot formation in the blood chamber of the pump, and once according to the standard protocol. RESULTS: LVAD use was consistently associated with enhanced adenosine diphosphate-induced platelet aggregation independent from the timing of clot formation or external pump exchange. Among coagulation indices, increased D-dimer holds predictive value for clot formation. The fibrinogen level peaked before the first pump exchange and was twice as high than the average values. Gradual improvement in exercise capacity was observed 2 years after implantation, after which the patient underwent a controlled stress test in the stop mode of the LVAD and the device was successfully explanted. CONCLUSIONS: Serial assessment of hemostatic biomarkers may benefit and triage LVAD patients. Consistent platelet activation during long-term LVAD may justify the addition of clopidogrel, while high D-dimer and/or elevated fibrinogen may indicate adding heparin to the conventional antithrombotic regimen. Randomized evidence is needed to test such a hypothesis.

Higher perfusion pressure and pump flow during cardiopulmonary bypass are beneficial for kidney function-a single-centre prospective study.

Background: Kidneys play an essential role in the circulatory system, regulating blood pressure and intravascular volume. They are also set on maintaining an adequate filtration pressure in the glomerulus. During the CPB, a decrease in systemic blood pressure and hemoglobin concentration may lead to renal ischemia and subsequent acute kidney injury. Methods: One hundred nine adult patients were prospectively enrolled in this study. The intervention in this study was increasing the flow of the CPB pump to reach the target MAP of > 90 mmHg during the procedure. The control group had a standard pump flow of 2.4 L/min/m2. Results: Standard pump flow of 2.4 L/min/m2 resulted in mean MAP < 90 mmHg during the CPB in most patients in the control group. Maintaining a higher MAP during CPB in this study population did not affect CSA-AKI incidence. However, it increased the intraoperative and postoperative diuresis and decreased renin release associated with CPB. Higher MAP during the CPB did not increase the incidence of cerebrovascular complications after the operation; patients in the highest MAP group had the lowest incidence of postoperative delirium, but the result did not obtain statistical significance. Conclusion: Maintaining MAP > 90 mmHg during the CPB positively impacts intraoperative and postoperative kidney function. It significantly reduces renal hypoperfusion during the procedure compared to MAP < 70 mmHg. MAP > 90 mmHg is safe for the central nervous system, and preliminary results suggest that it may have a beneficial impact on the incidence of postoperative delirium.

Single versus multiple arterial coronary artery bypass grafting in men and women: results from Polish National Registry of Cardiac Surgery Procedures.

BACKGROUND: The objective of this multicenter study aimed to investigate the impact of sex on long-term survival among patients with multivessel coronary artery disease undergoing coronary artery bypass grafting (CABG) using multiple arterial grafting (MAG) or a single artery with saphenous vein grafts. MATERIALS AND METHODS: Data were obtained from the Polish National Registry of Cardiac Surgery Procedures database. This study included 81 136 patients who underwent CABG for multivessel disease between January 2012 and December 2020 (22.9 were women and 77.1% were men). MAG was performed in 8.3 and 11.7% of female and male patients, respectively. A 1:1 propensity score (PS)-matching was performed. Long-term mortality was compared between matched groups of men and women. Subgroup analyses of patients aged <70 and ≥70 years, with an ejection fraction (EF) >40% and ≤40%, and with and without diabetes, obesity, peripheral artery disease (PAD), or chronic lung disease (CLD) were performed separately in women and men. RESULTS: MAG was associated with lower long-term mortality than saphenous vein grafts in 1528 PS-matched female pairs [hazard ratio (HR): 0.74; 95% CI: 0.59-0.92; P =0.007) and 7283 PS-matched male pairs (HR: 0.80; 95% CI: 0.72-0.88; P <0.001). Subgroup analyses confirmed the results among female patients aged <70 years, with diabetes and EF >40%, and without PAD or CLD, and of male patients aged <70 and ≥70 years; with EF >40%; with or without diabetes, obesity, or PAD; and without CLD. CONCLUSIONS: In patients undergoing CABG, MAG was associated with significantly improved survival in both sexes. The long-term benefits of MAG observed across subgroups of men and women support the consideration of a multiarterial revascularization strategy for a broader spectrum of patients.

Alterations to Kidney Physiology during Cardiopulmonary Bypass-A Narrative Review of the Literature and Practical Remarks.

INTRODUCTION: According to different authors, cardiac surgery-associated acute kidney injury (CSA-AKI) incidence can be as high as 20-50%. This complication increases postoperative morbidity and mortality and impairs long-term kidney function in some patients. This review aims to summarize current knowledge regarding alterations to renal physiology during cardiopulmonary bypass (CPB) and to discuss possible nephroprotective strategies for cardiac surgeries. Relevant sections: Systemic and renal circulation, Vasoactive drugs, Fluid balance and Osmotic regulation and Inflammatory response. CONCLUSIONS: Considering the available scientific evidence, it is concluded that adequate kidney perfusion and fluid balance are the most critical factors determining postoperative kidney function. By adequate perfusion, one should understand perfusion with proper oxygen delivery and sufficient perfusion pressure. Maintaining the fluid balance is imperative for a normal kidney filtration process, which is essential for preserving the intra- and postoperative kidney function. FUTURE DIRECTIONS: The review of the available literature regarding kidney function during cardiac surgery revealed a need for a more holistic approach to this subject.

The Rate of Postoperative Mortality and Renal and Respiratory Complications are Increased in Patients with Extreme Obesity Undergoing Cardiac Surgery - A Retrospective Observational Cohort Study of 8848 Patients.

Introduction: The importance of obesity as a potential risk factor in open heart surgery is well known. The epidemic of extreme obesity is an increasing public health concern and raises alerts regarding postoperative complications and mortality in patients undergoing cardiac surgery. The study aimed to analyze the impact of extreme obesity (BMI≥40) on the frequency of postoperative complications, as well as early and delayed mortality compared to patients with a lower body mass. Materials and Methodology: This retrospective observational cohort study involved patients, over the age of 18, undergoing cardiac surgery with cardiopulmonary bypass at the Cardiac Surgery Department of the Pomeranian Medical University in Szczecin, Poland between January 1st, 2010 and December 31st, 2018. The patients included in the study were allocated into two subgroups depending on the BMI index (Group I BMI≥40 vs Group II BMI<40). Results: A total of 8848 adult patients of both genders were included. Baseline characteristics for Group I and Group II were mean age 64.07±7.76 vs 65.10±9.68 years (p=0.123), mean BMI 42.13±2.44 vs 28.55±4.23 (p<0.001), with more females in Group I (58.04% vs 29.06%) and more males in Group II (70.94% vs 29.06%), p<0.001. The predicted perioperative risk using the EuroScore Logistics scale was higher in a group with BMI≥40 (p<0.001). Regression analysis with adjustment for confounding factors showed a statistically significant relationship between BMI≥40 and postoperative respiratory failure (OR=1.760, p=0.043), acute kidney injury AKIN2 (OR=2.082, p=0.044) and AKIN3 (OR=2.743, p=0.039). 30-day mortality in the univariate analysis showed a statistically significant relationship, however, after modifying the results with interfering factors, no statistical significance was obtained. Conclusion: The risk of postoperative acute respiratory failure and acute renal injury was increased in patients with BMI≥40. The probability of 30-day survival of patients after cardiac surgery was much lower in people with extreme obesity, although it was related to the dominant comorbidities. The 10-year survival was comparable in both groups.

More for less - long-term survival modeling for surgical aortic valve replacement follow-up: The division between a ministernotomy and a full sternotomy approach.

BACKGROUND: This study aimed to assess long-term results after surgical AVR (sAVR) depending on the used surgical technique (ministernotomy vs. full sternotomy) and to determine which patient- and treatment-related attributes were most associated with shorter time to the main endpoint. METHODS: Out of 2147 patients, who underwent sAVR from January 2006 to December 2017, 615 patients were treated minimally invasively (MIAVR) and 1532 patients received conventional full sternotomy aortic valve replacement (FSAVR). Multiple Cox regressive models corresponding to the four major endpoints were developed. Long-term survival and a time to re-hospitalization for acute coronary syndrome, stroke, and heart failure (HF) were analyzed independently. Kaplan-Meier actuarial analysis was performed for univariate comparison. RESULTS: The median follow-up time was 71.9 months. No significant difference in terms of long-term survival was found between MIAVR and FSAVR (hazard ratio [HR], 0.99; P = 0.91). Novel advantages of MIAVR in preventing re-hospitalization for late cerebrovascular events and the progression of HF were observed (HR, 0.53; P = 0.03; HR, 0.64, P = 0.005; respectively). Importantly, for the late mortality risk, early in-hospital complications dominated. However, the baseline atrial fibrillation (AF), diabetes, pulmonary disease, and impaired mobility showed the strongest patient-specific prediction for the other three long-run models. CONCLUSIONS: MIAVR through ministernotomy provides at least as good long-term survival as FSAVR. Nevertheless, it should be recommended for diabetic, poor-mobility patients with pre-existing AF to reduce their high cerebrovascular risk and to limit the progression of HF. MIAVR also needs to be considered in patients with chronic lung diseases to improve their extremely poor survival prognosis.

Ministernotomy for aortic valve replacement improves early recovery and facilitates proper wound healing - forced propensity score matching design with reference full sternotomy.

Introduction: With the development of less invasive techniques ministernotomy has become an increasingly popular choice for minimally invasive aortic valve replacement (MIAVR). However, a large discrepancy in the published results, often derived from the center's own experience, intensifies the need for further re-evaluation in order to better define the real impact of the ministernotomy approach on postoperative clinical condition in short- and long-term observation. Aim: To assess the safety and efficacy of MIAVR in comparison to a reference full sternotomy AVR (FSAVR). Material and methods: Between January 2004 and January 2018, 2386 patients underwent isolated surgical aortic valve replacement (AVR) at our institution. 620 patients were treated minimally invasively (MIAVR) and 1766 patients received FSAVR. Forced propensity score 1 : 1 matching and conditional regressive methods were introduced, ensuring valid comparison and correct estimation. Ultimately, 557 well allocated pairs of treated and control patients were included. Results: In-hospital mortality was low and comparable (1.26% for MIAVR, 1.62% for FSAVR). No significant differences in terms of serious adverse events were found, although in patients undergoing MIAVR there tended to be lower incidence of neurological complications (OR = 0.72; p = 0.09) and low output syndrome (OR = 0.66; p = 0.13). In addition to a much faster extubation and discharge from the ICU as well as improved blood management, MIAVR significantly reduced the risk of wound complications (OR = 0.31; p < 0.0010). Conclusions: MIAVR is a safe, effective and reproducible procedure providing at least as good results as FSAVR. Nevertheless, it should be especially recommended to obese, diabetic patients with pulmonary and mobility disorders in order to improve their early recovery.

Nonstandard usage of a left ventricular assist device in a patient with severe heart failure complicated by pulmonary artery thrombosis - case report.

BACKGROUND: Heart failure complicated by pulmonary embolism is an extremely rare condition described in the literature. We report a case of very young patient with advanced heart failure against the background of dilated cardiomyopathy of unknown etiology with the presence of blood clots in both ventricles. CASE PRESENTATION: The course of treatment was complicated by acute pulmonary embolism. In emergency setting the patient was qualified for combine surgery pulmonary embolization and implantation of a continuous flow pump as a bridge for heart transplantation. The post-operative course is described in detail as well as reimplantation of the pump due to early thrombosis. CONCLUSIONS: Performed surgical procedures combined with alteration in anticoagulant drugs was sufficient to stabilize the clinical condition.

Mechanical circulatory support restores eligibility for heart transplant in patients with significant pulmonary hypertension.

BACKGROUND: An increasing number of patients with end­stage heart failure implies a wider use of left ventricular assist devices (LVADs). Irreversible pulmonary hypertension (PH) is a predictor of unfavorable prognosis and a contraindication to orthotopic heart transplant (OHT). AIMS: The aim of this study was to evaluate the effect of continuous­flow LVAD (CF­LVAD) support on pulmonary pressure and pulmonary vascular resistance (PVR) as well as the impact of pre­LVAD hemodynamic parameters on survival during LVAD support. METHODS: Data collected from 106 patients who underwent CF­LVAD implantation in the years 2009 to 2018 (men, 95.3%; mean [SD] age, 51.8 [12] years; mean [SD] INTERMACS profile, 2.9 [1.6]; mean [SD] LVAD support time, 661 [520] days; follow­up until May 2019) were retrospectively analyzed. RESULTS: Right heart catheterization was performed before LVAD implantation in 94 patients (88.7%), after implantation-in 31 (29.2%), and before and after implantation-in 28 (26.4%). We observed mean pulmonary artery pressure (mPAP) >25 mm Hg in 65 patients (61.3%) and PVR >2.5 Wood units in 33 patients (31.1%) before LVAD implantation. A significant improvement after CF­LVAD implantation was noted in mPAP, pulmonary capillary wedge pressure, transpulmonary gradient, PVR, cardiac output (P <0.001 for all parameters), and cardiac index (P = 0.003). All patients with initially irreversible PH became eligible for OHT during LVAD support. Survival during LVAD support did not depend on initial mPAP and PVR. CONCLUSIONS: In patients with end­stage heart failure, CF­LVAD support leads to a significant reduction of pre­ and postcapillary PH. Survival on CF­LVAD support is independent of elevated mPAP and PVR before implantation, which suggests that LVADs decrease the risk associated with PH.

Short- and long-term outcomes of continuous-flow left ventricular assist device therapy in 79 patients with end-stage heart failure.

INTRODUCTION: An increasing number of patients with end­stage heart failure, along with a shortage of heart donors, necessitates the use of mechanical circulatory support. OBJECTIVES: This single­center retrospective study evaluated short- and long term outcomes of continuous­flow left ventricular assist device (CF LVAD) therapy in patients with end stage heart failure. PATIENTS AND METHODS: We collected and assessed data of 79 patients (77 men, 2 women; mean age, 50.3 years; mean INTERMACS profile, 3.1) implanted with a CF­LVAD between 2009 and 2017 (HeartMate 3 in 19 patients [24%]; HeartMate 2 in 9 [11.4%]; and HeartWare in 51 [64.6%]). RESULTS: The mean time on CF-LVAD support was 604 days (range, 1­1758 days). There were 2 device exchanges due to pump thrombosis and 1 explantation due to heart regeneration; 9 patients (11.4%) underwent heart transplant. Stroke (nondisabling, 48%) occurred in 27.8% of patients (ischemic in 9 patients; hemorrhagic, in 14; both types, in 1) despite the standardized anticoagulation regimen. Major gastrointestinal bleeding and pump thrombosis were reported in 13 patients (16.5%), while 18 patients (22.8%) developed driveline infections (recurrent in 15 patients [19%]). Hemorrhagic stroke and bacteremia had a negative impact on survival. Hemorrhagic stroke was the main cause of death. Survival probability was 0.9 at 1 month and 0.81, 0.71, 0.61, and 0.53 at 1, 2, 3, and 4 years, respectively. CONCLUSIONS: Although CF­LVAD support is associated with substantial adverse events, they do not significantly affect mortality (except hemorrhagic stroke and bacteremia). Novel devices seem to overcome these limitations, but larger studies are needed to support these findings.

[Pulmonary hypertension]. / O nadcisnieniu plucnym.

Pulmonary hypertension is characterized by a progressive increase in pulmonary arterial pressure in association with dilatation and hypertrophy of the right ventricle, causing gradual reduction in ejection fraction. The increase in mean pulmonary arterial pressure may be passive, due to increased downstream pressure, hyperkinetic due to increased cardiac output, or due to increased pulmonary vascular resistance resulting from changes in the pulmonary vessels. In an advanced stage of pulmonary hypertension there may be right ventricular dilatation and hypertrophy, tricuspid regurgitation and septal deviation, with consequent effects on cardiac function. Clinical symptoms are not specific. Until recently, the treatment of pulmonary hypertension was limited to anticoagulation, supplementary oxygen and high-dose calcium channel blockers, in association with diuretics and digoxin where indicated. Recently approved treatments are nitric oxide, sildenafil--a phosphodiesterase-5 inhibitor, analogs of prostacyclin, and nonselective and selective endothelin receptor inhibitors. Surgery and anaesthesia pose a significant risk for patients with pulmonary hypertension. Right ventricular failure, persistent postoperative hypoxia and coronary ischaemia are among the potential postoperative complications.

[Regional citrate anticoagulation for continuous haemodiafiltration in the postoperative period]. / Ostra pooperacyjna niewydolnosc nerek leczona hemodiafiltracja z wykorzystaniem regionalnej antykoagulacji.

BACKGROUND: Continuous renal replacement therapy (CRRT) is commonly used for the treatment of acute renal failure in haemodynamically unstable patients after cardiac surgery. The main problem associated with CRRT is the need for systemic anticoagulation that may lead to bleeding complications. As an alternative to heparins, and to avoid systemic anticoagulation, the use of regional citrate infusion has been proposed for patients with a high risk of bleeding. CASE REPORTS: We present the clinical course of three patients with a high risk of bleeding after cardiac surgery in which CRRT, based on regional citrate anticoagulation, was conducted safely. Circuit survival times were over 80 hours and filters were changed on schedule, without any signs of dysfunction. Metabolic alkalosis was observed in one patient, who was treated by reducing the circuit blood flow and increasing the dialisate flow. One patient required chronic dialysis, the other two recovering after short-term CRRT. CONCLUSION: Regional citrate anticoagulation during CRRT should be used as a method of choice in patients with a high risk of haemorrhage in the postoperative period.

[The protocol for multi organ donor management]. / Przygotowanie dawcy do pobrania wielonarzqdowego--standard postepowania.

Identification and preparation of a potential organ donor requires careful and meticulous intensive care, so that the organs may be harvested in the best possible condition for transplantation. The protocol consists of three key elements: (1) monitoring and haemodynamicstabilisation, (2) hormonal therapy, and (3) adequate mechanical ventilation and nosocomial pneumonia prophylaxis. Standard haemodynamic monitoring should consist of a 12 lead EGG, and direct monitoring of arterial and central venous pressures. Pulmonary artery catheterisation is indicated in donors with a left ventricular ejection fraction (LVEF) below 45%. PCWP should be kept at around 12 mm Hg, Cl at greater than 2.4 L m(-2), and SVR between 800 and 1200 dyn s(-1) cm(-5). When a vasopressor is necessary, vasopressin should be used as the drug of choice. If vasopressin is not available, noradrenaline or adrenaline may be used. Haemoglobin concentration should be maintained between 5.5-6.2 mmol L(-1). In a potential heart donor, troponin concentration should be checked daily. Neutral thermal conditions should be maintained using a warm air blower. A brain dead patient cannot maintain adequate pituitary function, therefore hormone replacement therapy with methylprednisolone, thyroxin and desmopressin is indicated. Glucose concentrations should be kept within the normal range, using insulin if necessary. The lung harvesting protocol should be similarto ARDS treatment guidelines (optimal PEEP, low tidal volumes). Lung recruitment manoeuvres, and aggressive prevention and treatment of nosocomial infection are essential.

Myofibrillolysis and fibrosis predicts myocardial insufficiency.

INTRODUCTION: Cardiocyte myofibrillolysis and interstitial fibrosis belong to histopathological changes in cardiomyopathies, leading to heart failure. AIM: To evaluate these changes in apical resection during left ventricular assist device (LVAD) implantation. MATERIAL AND METHODS: The studied group consisted of 40 patients with cardiomyopathy, and apical samples excised during left ventricular assist device implantation were studied (CM/VAD group, mean: 48.1 ±10 y/o). A control group consisted of 6 apical samples from healthy heart graft donors (mean: 29 ±2.3 years old). Area fraction (AF) was calculated for: fibrosis, cardiocytes with myofibrillolysis (MFL), non-myofibrillolytic cardiocytes (non-MFL). RESULTS: Single lymphocytes were seen in 18 (45%) cases in the CM/VAD group. Cardiomyopathy grade evaluated semiquantitatively in CM/VAD was: slight (25% of a group), moderate (35.5%), advanced (35.5%). CM/VAD cases showed nearly ten times higher fibrosis than the control group. The MFL cells occupied nearly a five times larger area in CM/VAD than in the control group, whereas non-MFL cells were found in the control group, as a predominant pattern. The linear regression calculated between fibrosis AF and types of cardiocytes indicated the depletion of cardiomyocytes with fibrosis increase. The control group presented insignificant dependency between fibrosis and MFL cells, suggesting the lack of replacement fibrosis. Significant negative dependence between fibrosis and non-MFL cardiocytes suggested remodeling in controls. Correlation analysis showed a strong relation between depletion of normal cardiocytes and progression of fibrosis. CONCLUSIONS: Progression of cardiomyopathy and fibrosis depends on the loss of cardiocytes rather than degeneration of these cells.

Simplified, less-invasive left ventricular assist device implantation in patients with post-coronary artery bypass grafting.

Less-invasive left ventricular assist device implantation is becoming the technique of choice for implementation of new-generation heart pumps. The less-invasive technique is particularly useful for patients with a history of cardiac surgical procedures, such as coronary artery bypass grafting. Yet, in redo cases, severe pericardial adhesions may force experienced operators to opt for alternative outflow graft placement, such as in the descending aorta. We propose a surgical technique in which the left ventricular device is implanted through a limited thoracic incision, with the outflow graft anastomosed to the ascending aorta, avoiding collision with coronary bypass grafts. The key element of the proposed technique is a tunnel connecting 2 pleural cavities, in which the outflow graft is placed, entirely bypassing the pericardium.