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[This corrects the article DOI: 10.3389/ti.2023.11675.].
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Despite the withdrawal of the HeartWare Ventricular Assist Device (HVAD), hundreds of patients are still supported with this continuous-flow pump, and the long-term management of these patients is still under debate. This study aims to analyse 5 years survival and freedom from major adverse events in patients supported by HVAD and HeartMate3 (HM3). From 2010 to 2022, the MIRAMACS Italian Registry enrolled all-comer patients receiving a LVAD support at seven Cardiac Surgery Centres. Out of 447 LVAD implantation, 214 (47.9%) received HM3 and 233 (52.1%) received HVAD. Cox-regression analysis adjusted for major confounders showed an increased risk for mortality (HR 1.5 [1.2-1.9]; p = 0.031), for both ischemic stroke (HR 2.08 [1.06-4.08]; p = 0.033) and haemorrhagic stroke (HR 2.6 [1.3-4.9]; p = 0.005), and for pump thrombosis (HR 25.7 [3.5-188.9]; p < 0.001) in HVAD patients. The propensity-score matching analysis (130 pairs of HVAD vs. HM3) confirmed a significantly lower 5 years survival (81.25% vs. 64.1%; p 0.02), freedom from haemorrhagic stroke (90.5% vs. 70.1%; p < 0.001) and from pump thrombosis (98.5% vs. 74.7%; p < 0.001) in HVAD cohort. Although similar perioperative outcome, patients implanted with HVAD developed a higher risk for mortality, haemorrhagic stroke and thrombosis during 5 years of follow-up compared to HM3 patients.
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Coração Auxiliar , Acidente Vascular Cerebral Hemorrágico , Humanos , Sistema de Registros , Pontuação de Propensão , Fenômenos MagnéticosRESUMO
OBJECTIVE: Aim of this study is to evaluate short term safety and efficacy of Impella in high risk percutaneous coronary intervention (HR-PCI) population. BACKGROUND: While several studies demonstrated the clinical significance of Impella in HR-PCI, few data exist about its impact on short term outcome. METHODS: All studies reporting short term outcomes of PCI with any Impella device were included. The primary endpoint was either in-hospital or 30-day mortality, while vascular complications, post-procedural stroke, post-procedural dialysis and bleeding complications were assessed as secondary outcomes. RESULTS: Nine studies with 7448 patients were included. Median age was 69.5 years old (67-73), with a mean ejection fraction of 29.7% (20%-39%) and a Syntax score of 30.2 (25. 5-33, interquartile [IQR]). Impella 2.5 was the most commonly used axial flow pump used to support these PCIs (88.7%). In-hospital death was observed in 5.09% of patients (95% confidence interval [CI] 3.69-6.49, I2 = 78%), while vascular complications in 2.53% of patients (1.07-4.00, I2 = 89%) and post-procedural stroke in 2.77% of patients (0.50-6.05, I2 = 98%). Major bleeding occurred in 5.98% of patients (3.66-8.31, I2 = 90%) and post-procedural dialysis in 4.44% of patients (1.50-7.37, I2 = 93% all CI 93%). CONCLUSION: Use of Impella in high risk PCI appears to have an acceptable rate of complication, especially regarding vascular complications and major bleedings.
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Coração Auxiliar , Intervenção Coronária Percutânea , Idoso , Coração Auxiliar/efeitos adversos , Mortalidade Hospitalar , Humanos , Intervenção Coronária Percutânea/efeitos adversos , Estudos Retrospectivos , Volume Sistólico , Resultado do TratamentoRESUMO
BACKGROUND: Traditionally, pain management after left ventricular assist device (LVAD) implantation via median sternotomy have been based on intravenous opioids but, in the era of enhanced recovery after surgery, a multimodal opioid-sparing analgesia could represent a valid alternative reducing opioids related side effects. CASE REPORT: We described the successfully use of an opioid-sparing regimen for pain management after LVAD implantation via median sternotomy based on two ultrasound-guided fascial plane wall blocks. Bilateral ultrasound-guided transversus thoracic plane block was performed to manage sternotomy pain; additionally, unilateral left ultrasound-guided rectus sheath block was performed to provide somatic pain relief for left abdominal wall structures superficial to the peritoneum within which the LVAD driveline was inserted. The patient was extubated on Day 1 and good quality analgesia (numerical rating scale <3) was obtained, without using nonsteroidal antiinflammatory drugs or opioids. The patient was discharged from Intensive Care Unit on Day 3 and during hospitalization (lasted 24 days) there was no need for rescue analgesia administration.
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Parede Abdominal , Coração Auxiliar , Bloqueio Nervoso , Analgésicos Opioides , Humanos , Dor Pós-Operatória/tratamento farmacológico , Dor Pós-Operatória/prevenção & controle , EsternotomiaRESUMO
The high incidence of out-of-hospital cardiac arrest refractory to standard resuscitation protocols, despite precompetitive screening, demonstrated the need for a prehospital team to provide an effective system for life support and resuscitation at the Volleyball Men's World Championship. The evolution of mechanical circulatory support suggests that current advanced cardiovascular life support protocols no longer represent the highest standard of care at competitive sporting events with large spectator numbers. Extracorporeal life support (ECLS) improves resuscitation strategies and offers a rescue therapy for refractory cardiac arrest that can no longer be ignored. We present our operational experience of an out-of-hospital ECLS cardiopulmonary resuscitation team at an international sporting event.
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Reanimação Cardiopulmonar , Oxigenação por Membrana Extracorpórea , Parada Cardíaca Extra-Hospitalar , Voleibol , Reanimação Cardiopulmonar/métodos , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Itália , Masculino , Parada Cardíaca Extra-Hospitalar/etiologia , Parada Cardíaca Extra-Hospitalar/terapiaRESUMO
BACKGROUND: The aim of this study was to evaluate the impact of the surgical approach on the postoperative outcome in patients who underwent left ventricular assist device (LVAD) implantation after having received veno-arterial extracorporeal life support (va-ECLS) using data from a European registry (ECLS-VAD). Five hundred and thirty-one patients were included. METHODS: A propensity score-adjusted outcome analysis was performed, resulting in 324 patients in the full sternotomy (FS) group and 39 in the less invasive surgery (LIS) group. RESULTS: The surgery lasted in median 236 min in the FS group versus 263 min in the LIS group (p = 0.289). The median chest tube output during the first 24 h was similar in both groups. Patients who underwent implantation with an FS required more blood products during the first 24 postoperative hours (median 16 vs. 12, p = 0.033). The incidence of revision due to bleeding was also higher (35.5 vs. 15.4%, p = 0.016). A temporary postoperative right ventricular assist device was necessary in 45.1 (FS) versus 23.1% (LIS) of patients, respectively (p = 0.067). No stroke occurred in the LIS group during the first 30 days after surgery (7.4% in the FS group). The incidence of stroke and of renal, hepatic, and respiratory failure during the follow-up was similar in both groups. The 30-day and one-year survival were similar in both groups. CONCLUSION: LIS for implantation of a durable LVAD in patients on va-ECLS implanted for cardiogenic shock is associated with less revision due to bleeding, less administration of blood products and absence of perioperative stroke, with no impact on survival.
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Oxigenação por Membrana Extracorpórea , Insuficiência Cardíaca , Coração Auxiliar , Insuficiência Cardíaca/cirurgia , Humanos , Implantação de Prótese , Estudos Retrospectivos , Resultado do TratamentoRESUMO
We report a case of a patient supported with a HeartWare left ventricular assist device for idiopathic cardiomyopathy who was resistance to vitamin-K antagonists three months after implantation. The patient initially started low-molecular-weight heparin therapy and then, after the onset of an ischemic stroke, switched to dabigatran etexilate (DE). The patient had progressive recovery of cardiac function for which the device was explanted. No thrombotic or bleeding events occurred during DE therapy.
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Cardiomiopatia Dilatada/cirurgia , Dabigatrana/administração & dosagem , Coração Auxiliar , Cuidados Pós-Operatórios/métodos , Trombose/prevenção & controle , Vitamina K/antagonistas & inibidores , Idoso , Antitrombinas/administração & dosagem , Feminino , Seguimentos , Coração Auxiliar/efeitos adversos , Humanos , Trombose/etiologiaRESUMO
A limit of peripheral veno-arterial Extracorporeal Membrane Oxigenator (VA-ECMO) is the inadequate unloading of the left ventricle. The increase of end-diastolic pressure reduces the possibility of a recovery and may cause severe pulmonary edema. In this study, we evaluate our results after implantation of VA-ECMO and Transapical Left Ventricular Vent (TLVV) as a bridge to recovery, heart transplantation or long-term left ventricular assit devices (LVAD). From 2011 to 2014, 24 consecutive patients with profound cardiogenic shock were supported by peripheral VA-ECMO as bridge to decision. In all cases, TLVV was implanted after a mean period of 12.2 ± 3.4 hours through a left mini-thoracotomy and connected to the venous inflow line of the VA-ECMO. Thirty-day mortality was 37.5% (9/24). In all patients, hemodynamics improved after TLVV implantation with an increased cardiac output, mixed venous saturation and a significant reduced heart filling pressures (p < .05). Recovery of the cardiac function was observed in 11 patients (11/24; 45.8%). Three patients were transplanted (3/24; 12.5%) and three patients (3/24; 12.5%) underwent LVAD implantation as destination therapy, all these patients were discharged from the hospital in good clinical conditions. In these critical patients, systematic TLVV improved hemodynamic seemed to provide better in hospital survival and chance of recovery, compared to VA-ECMO results in the treatment of cardiogenic shock reported in the literature . TLVV is a viable alternative to standard VA-ECMO to identify the appropriate long-term strategy (heart transplantation or long-term VAD) reducing the risk of treatment failure. A larger and multicenter experience is mandatory to validate these hypothesis.
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Oxigenação por Membrana Extracorpórea/métodos , Ventrículos do Coração/fisiopatologia , Choque Cardiogênico/terapia , Adolescente , Adulto , Suporte Vital Cardíaco Avançado , Idoso , Feminino , Coração Auxiliar , Máquina Coração-Pulmão , Hemodinâmica/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , Oxigenadores de Membrana , Estudos Retrospectivos , Adulto JovemAssuntos
Neoplasias das Glândulas Suprarrenais , Oxigenação por Membrana Extracorpórea , Feocromocitoma , Neoplasias das Glândulas Suprarrenais/complicações , Neoplasias das Glândulas Suprarrenais/diagnóstico por imagem , Neoplasias das Glândulas Suprarrenais/cirurgia , Adrenérgicos , Humanos , Feocromocitoma/complicações , Feocromocitoma/diagnóstico por imagem , Feocromocitoma/cirurgia , Choque Cardiogênico/etiologia , Choque Cardiogênico/terapiaAssuntos
COVID-19 , Transplante de Coração , Transplante de Fígado , Surtos de Doenças , Humanos , Itália , Pandemias , SARS-CoV-2RESUMO
Iatrogenic left main coronary artery and aortic root dissection are rare complications during coronary catheterization. A case of catheter-induced left main coronary artery dissection with subsequent retrograde progression into the ascending aorta wall is reported. The patient was surgically managed with an ascending aorta replacement and left coronary ostial repair with an autologuos aortic wall ring-shaped patch in the paraostial position in order to seal the intimal tear.
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Aorta/transplante , Implante de Prótese Vascular/métodos , Cateterismo Cardíaco/efeitos adversos , Anomalias dos Vasos Coronários/etiologia , Vasos Coronários/cirurgia , Doença Iatrogênica , Doenças Vasculares/congênito , Procedimentos Cirúrgicos Vasculares/métodos , Idoso , Aorta/patologia , Aorta/cirurgia , Anomalias dos Vasos Coronários/patologia , Humanos , Masculino , Transplante Autólogo , Doenças Vasculares/etiologia , Doenças Vasculares/patologiaRESUMO
Mechanical prosthesis is the first choice for valve replacement at the mitral position in children. Replacement of the original prosthesis because of prosthesis-patient mismatch (PPM) is almost inevitable when prostheses are implanted in small children. The impact of PPM on long-term mortality becomes significant when the effective orifice area (EOA) is severely reduced. In these cases prosthesis replacement can be technically difficult, and it often requires extended enlargement of the mitral valve annulus ring. We report a case of a woman who underwent a mitral valve replacement with a 19-mm St. Jude mechanical prosthetic valve at the age of 3 years. At the age of 33 years, the patient underwent a successful minimally invasive mitral annulus ring enlargement and implantation of a 23-mm St. Jude mechanical prosthetic valve via a right minithoracotomy.
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Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Anuloplastia da Valva Mitral/instrumentação , Anuloplastia da Valva Mitral/métodos , Estenose da Valva Mitral/etiologia , Estenose da Valva Mitral/cirurgia , Ajuste de Prótese/efeitos adversos , Adulto , Terapia Combinada , Feminino , Implante de Prótese de Valva Cardíaca/instrumentação , Humanos , Estenose da Valva Mitral/diagnóstico , Reoperação/instrumentação , Reoperação/métodos , Resultado do TratamentoRESUMO
A sudden, unexpected, reversible, severe left ventricular dysfunction, mimicking an acute myocardial infarction without demonstrable obstructive coronary artery stenosis, was first recognized in Japan in 1990 and originally termed takotsubo cardiomyopathy. In 2006, the American Heart Association included takotsubo cardiomyopathy into its classification of primary acquired cardiomyopathy. The true incidence of takotsubo cardiomyopathy in the community is difficult to estimate. In fact, despite an increasing awareness, this syndrome has to date been under-recognized and misdiagnosed, mainly because of the transitory natures of its clinical and instrumental features. The study aim was to investigate the association between the occurrence of takotsubo cardiomyopathy and emotional or physical stressors, as described also in the setting of various surgical procedures. The case is also described of a 77-year-old woman who suffered a transient left ventricular dysfunction soon after cardiac surgery for valvular disease and epicardial cryoablation of atrial fibrillation.
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Implante de Prótese de Valva Cardíaca/efeitos adversos , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Insuficiência da Valva Mitral/cirurgia , Valva Mitral/cirurgia , Complicações Pós-Operatórias , Cardiomiopatia de Takotsubo/etiologia , Idoso , Feminino , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Cardiomiopatia de Takotsubo/diagnósticoRESUMO
The use of ECPELLA in patients with severe lung disease may result in an unfavorable phenomenon of differential hypoxia. The simultaneous evaluation of three arterial blood samples from different arterial line (right radial artery, left radial artery, ECMO arterial line) in patients at risk of Harlequin syndrome (also called differential hypoxemia (DH)) can localize the "mixing cloud" along the aorta. Focusing the attention on the "mixing cloud" position instead of on isolated flows of Veno-Arterial Extracorporeal Membrane Oxygenation (VA ECMO) and Impella CP makes the decision making easier about how to modify MCSs flows according to the clinical context. Herein, we present two cases in which ECPELLA configuration was used to treat a cardiogenic shock condition and how the ECPELLA-induced hypoxia was managed.
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Doenças do Sistema Nervoso Autônomo , Hipo-Hidrose , Humanos , Hipo-Hidrose/complicações , Hipo-Hidrose/terapia , Aorta , HipóxiaRESUMO
Stroke is one of the leading complications following durable mechanical circulatory support (MCS) implantation. The aim of this multicenter study was to investigate stroke complications in patients requiring durable MCS following extracorporeal life support (ECLS). Data of 11 high volume MCS centers were collected and evaluated to identify patients who underwent durable MCS implantation after ECLS support between January 2010 and August 2018. The primary outcome was stroke following durable MCS implantation. Univariate and multivariate logistic regression analyses were performed to determine predictors of stroke. Overall, 531 patients met the inclusion criteria. Only patients who were supported with continuous flow pumps were included in this study accounting for 495 patients (median age 54 years old [interquartile range 47-60]). A total of 136 patients (27%) developed postoperative stroke on device during the follow-up (48% ischemic and 52% hemorrhagic) after a median durable MCS support of 320 [32-1,000] days, accounting for 0.17 events per patient-year. Of 133 patients with known date of stroke, a total of 47 (10%) developed stroke during the first 30 days (64% ischemic and 36% hemorrhagic), and 86 patients developed stroke after 30 days (38% ischemic and 62% hemorrhagic) of durable MCS support (late stroke). Survival rate was significantly lower in patients with hemorrhagic stroke ( p = 0.00091). Stroke appears to be a common complication in patients transitioned to durable MCS support after ECLS. Hemorrhagic stroke is a more common type of late stroke and is associated with inferior outcomes.
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Oxigenação por Membrana Extracorpórea , Insuficiência Cardíaca , Coração Auxiliar , Acidente Vascular Cerebral Hemorrágico , Humanos , Pessoa de Meia-Idade , Oxigenação por Membrana Extracorpórea/efeitos adversos , Acidente Vascular Cerebral Hemorrágico/etiologia , Coração Auxiliar/efeitos adversos , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Insuficiência Cardíaca/cirurgiaRESUMO
OBJECTIVES: The Durable Mechanical Circulatory Support System After Extracorporeal Life Support registry is a multicenter registry of patients who were bridged from extracorporeal life support to a durable mechanical circulatory support system. Although numerous studies have highlighted the favorable outcomes after implantation of the HeartMate 3 (Abbott), the objective of our study is to examine the outcomes of patients who received HeartMate 3 support after extracorporeal life support. METHODS: Data of patients undergoing HeartMate 3 implantation from January 2016 to April 2022 at 14 centers were collected and evaluated. Inclusion criteria were patients with extracorporeal life support before HeartMate 3 implantation. The outcome was reported and compared with patients receiving other types of pumps. RESULTS: A total of 337 patients were bridged to durable mechanical circulatory support system after extracorporeal life support in the study period. Of those patients, 140 were supported with the HeartMate 3. The other types of pumps included 170 HeartWare HVADs (Medtronic) (86%), 14 HeartMate II devices (7%), and 13 (7%) other pumps (7%). Major postoperative complications included right heart failure requiring temporary right ventricular assist device in 60 patients (47%). Significantly lower postoperative stroke (16% vs 28%, P = .01) and pump thrombosis (3% vs 8%, P = .02) rates were observed in the patients receiving the HeartMate 3. The 30-day, 1-year, and 3-year survivals in patients receiving the HeartMate 3 were 87%, 73%, and 65%, respectively. CONCLUSIONS: In this critically ill patient population, the survivals of patients who were transitioned to the HeartMate 3 are deemed acceptable and superior to those observed when extracorporeal life support was bridged to other types of durable mechanical circulatory support systems.
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Persistence of heart failure symptoms or suboptimal hemodynamic is a frequent condition in LVAD carriers, associated with adverse outcome. Invasive hemodynamic optimization was associated with a better outcome. Our group recently validated an echocardiographic protocol to noninvasively assess hemodynamics of LVAD patients. Aim of this prospective study was to investigate its utility in clinical practice and its prognostic role. From February 2016 to February 2019 fifty-five LVAD carriers (HVAD/HM3 34/21; age 61 ± 10 years, 89% males; INTERMACS profile at LVAD implantation ≤3 68%). A two-phased protocol was performed. First, the patient underwent clinical evaluation. Second, an echo-Doppler blinded to clinical data was performed. Clinical and echo-Doppler evaluation both identified patients with "optimal hemodynamic profile" (normal left and right estimated atrial pressures) versus other profiles. clinical evaluation overestimated the presence of an optimal profile compared with echo-Doppler (83% vs. 59%). The presence of overt heart failure identified patients with the highest risk of adverse outcomes (death or hospitalization for HF at 6 months: HR 15, 95% CI, 5.5-39, P < 0.001). An optimal profile by echo-Doppler was associated with a better outcome among patients without overt heart failure (death or hospitalization for HF at 6 months: HR 0.08, 95% CI, 0.01.5-0.64, P < 0.02). After echo-Doppler, the clinician modified treatment in 46 cases (37%). Noninvasive evaluation of hemodynamics by echo-Doppler adds significant prognostic information in LVAD patients without overt HF and is a valuable tool to tailor treatment in the outpatient follow-up of LVAD carriers. Visual abstract: http://links.lww.com/ASAIO/A783.
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Insuficiência Cardíaca , Coração Auxiliar , Masculino , Humanos , Pessoa de Meia-Idade , Idoso , Feminino , Coração Auxiliar/efeitos adversos , Estudos Prospectivos , Prognóstico , Função Ventricular Esquerda , Hemodinâmica , Insuficiência Cardíaca/cirurgia , Insuficiência Cardíaca/complicações , Resultado do TratamentoRESUMO
OBJECTIVES: Implanting a durable left ventricular assist device (LVAD) in a patient on extracorporeal life support (ECLS) is challenging. The goal of this study was to compare the results of patients from a European registry who had a durable LVAD implanted with or without transition from ECLS to cardiopulmonary bypass (CPB). METHODS: A total of 531 patients on ECLS support who had an LVAD implant between January 2010 and August 2018 were analysed; after 1:1 propensity score matching, we identified and compared 175 patients in each group. RESULTS: The duration of preoperative ECLS was 7 [standard deviation (SD) 6] vs 7 (SD 6) days in patients with or without CPB (P = 0.984). The surgical time was longer in the CPB group [285 (SD 72) vs 209 [SD 75] min; P ≤ 0.001). The postoperative chest tube output was comparable [1513 (SD 1311) vs 1390 (SD 1121) ml; P = 0.3]. However, re-exploration for bleeding was necessary in 41% vs 29% of patients with or without CPB (P = 0.01) and a significantly higher number of packed red blood cells and fresh frozen plasma [8 (SD 8) vs 6 (SD 4) units; P = 0.001 and 6 (SD 7) vs 5 (SD 5) units; P = 0.03] were administered to patients operated on with CPB. A postoperative mechanical right ventricular support device was necessary in 50% vs 41% of patients (P = 0.08). The stroke rate was not significantly different (P 0.99). No difference in survival was observed. CONCLUSIONS: Omitting CPB for an LVAD implant in patients on ECLS is safe and results in shorter operating time, less re-exploration for bleeding and fewer blood products. However, no survival benefit is observed.