Post-myocardial infarction ventricular septal defect repair via right ventriculotomy with concomitant durable Heartmate 3 implantation after bridging with Impella 5.5.

In patients with post-myocardial infarction ventricular septal defects, temporary left ventricular support using Impella 5.5 can decrease shunting, facilitate peri-infarct tissue remodeling, and allow for assessment of myocardial recovery prior to repair. When there is inadequate cardiac recovery, implantation of a durable left ventricular assist device such as HeartMate 3 at time of repair can be safely performed. A right ventriculotomy provides multiple advantages when performing VSD repair and concomitant HeartMate 3 placement.

A report of transcatheter aortic valve insertion in a patient with chronic type B aortic dissection.

A 72-year-old man presented with symptomatic, severe aortic valve stenosis and a chronic descending thoracic aorta dissection with descending thoracic aortic aneurysm. After careful consideration, a transcatheter aortic valve was inserted through a transfemoral approach. This case demonstrates feasibility, and consideration should be given to this approach in patients requiring intervention for aortic stenosis.

Combined Heart-Kidney Transplant Versus Sequential Kidney Transplant in Heart Transplant Recipients.

OBJECTIVES: In patients with reduced kidney function there are no established guidelines to suggest combined heart-kidney transplant (HKTx) versus sequential kidney transplant (SKTx) using preoperative value of estimated glomerular filtration (eGFR). METHODS: The United Network for Organ Sharing database was queried from 2000 to 2015 to evaluate survival of HKTx and SKTx population stratified by preoperative eGFR rate <45 mL/min. Aim of the study was to assess the eGFR rate that is most beneficial to perform a concomitant or a SKTx at time of transplant evaluation. RESULTS: In our analysis, patients who required SKTx are recipients that, after heart transplantation, developed or worsened kidney insufficiency due to calcineurin inhibitor nephrotoxicity. In recipients with eGFR <30 or dialysis, a total of 545 received HKTx and 80 received SKTx. The median waiting time between heart and kidney transplant in SKTx group was 6 years. The overall post-transplant survival was 81% and 80% and 75% and 59% at 5 and 1 years for the HKTx and SKTx groups, respectively (P = .04). In recipients with eGFR from 30 to 44, a total of 107 received HKTx and 112 received SKTx. The median waiting time between heart and kidney transplant in SKTx group was 4 years. Overall post-transplant survival showed no statistically significant differences in HKTx group (n=107) compared with SKTx group (n=112) and was 90% and 95% at 1 year and 74% and 52% at 5 years, respectively (P = .4) . CONCLUSIONS: To optimize organ and patient survival, eGFR value can be utilized to discern between HKTx versus SKTx in patients with decreased renal function at the time of heart transplantation. Patients with eGFR<30 or in dialysis presented better survival with HKTx, while both SKTx and HKTx are suitable for patients with eGFR between 30 and 45.

In-vitro evaluation of limitations and possibilities for the future use of intracorporeal gas exchangers placed in the upper lobe position.

The lack of donor organs has led to the development of alternative "destination therapies", such as a bio-artificial lung (BA) for end-stage lung disease. Ultimately aiming at a fully implantable BA, general capabilities and limitations of different oxygenators were tested based on the model of BA positioning at the right upper lobe. Three different-sized oxygenators (neonatal, paediatric, and adult) were tested in a mock circulation loop regarding oxygenation and decarboxylation capacities for three respiratory pathologies. Blood flows were imitated by a roller pump, and respiration was imitated by a mechanical ventilator with different FiO2 applications. Pressure drops across the oxygenators and the integrity of the gas-exchange hollow fibers were analyzed. The neonatal oxygenator proved to be insufficient regarding oxygenation and decarboxylation. Despite elevated pCO2 levels, the paediatric and adult oxygenators delivered comparable sufficient oxygen levels, but sufficient decarboxylation across the oxygenators was ensured only at flow rates of 0.5 L min. Only the adult oxygenator indicated no significant pressure drops. For all tested conditions, gas-exchange hollow fibers remained intact. This is the first study showing the general feasibility of delivering sufficient levels of gas exchange to an intracorporeal BA via patient's breathing, without damaging gas-exchange hollow fiber membranes.

Left ventricular assist devices: current controversies and future directions.

Advanced heart failure is a growing epidemic that leads to significant suffering and economic losses. The development of left ventricular assist devices (LVADs) has led to improved quality of life and long-term survival for patients diagnosed with this devastating condition. This review briefly summarizes the short history and clinical outcomes of LVADs and focuses on the current controversies and issues facing LVAD therapy. Finally, the future directions for the role of LVADs in the treatment of end-stage heart failure are discussed.

Venovenous extracorporeal membrane oxygenation after cardiac arrest for acute respiratory distress syndrome caused by Legionella: a case report.

BACKGROUND: Legionella remains underdiagnosed in the intensive care unit and can progress to acute respiratory distress syndrome (ARDS), multiorgan failure and death. In severe cases, venovenous extracorporeal membrane oxygenation (VV-ECMO) allows time for resolution of disease with Legionella-targeted therapy. VV-ECMO outcomes for Legionella are favorable with reported survival greater than 70%. Rapid molecular polymerase chain reaction (PCR) testing of the lower respiratory tract aids in diagnosing Legionella with high sensitivity and specificity. We present a unique case of a patient with a positive COVID-19 test and ARDS who suffered a cardiac arrest. The patient was subsequently cannulated for VV-ECMO, and after lower respiratory tract PCR testing, Legionella was determined to be the cause. She was successfully treated and decannulated from VV-ECMO after eight days. CASE PRESENTATION: A 53-year-old female presented with one week of dyspnea and a positive COVID-19 test. She was hypoxemic, hypotensive and had bilateral infiltrates on imaging. She received supplemental oxygen, intravenous fluids, vasopressors, broad spectrum antibiotics, and was transferred to a tertiary care center. She developed progressive hypoxemia and suffered a cardiac arrest, requiring ten minutes of CPR and endotracheal intubation to achieve return of spontaneous circulation. Despite mechanical ventilation and paralysis, she developed refractory hypoxemia and was cannulated for VV-ECMO. Dexamethasone and remdesivir were given for presumed COVID-19. Bronchoscopy with bronchoalveolar lavage (BAL) performed with PCR testing was positive for Legionella pneumophila and negative for COVID-19. Steroids and remdesivir were discontinued and she was treated with azithromycin. Her lung compliance improved, and she was decannulated after eight days on VV-ECMO. She was discharged home on hospital day 16 breathing room air and neurologically intact. CONCLUSIONS: This case illustrates the utility of rapid PCR testing to diagnose Legionella in patients with respiratory failure and the early use of VV-ECMO in patients with refractory hypoxemia secondary to Legionella infection. Moreover, many patients encountered in the ICU may have prior COVID-19 immunity, and though a positive COVID-19 test may be present, further investigation with lower respiratory tract PCR testing may provide alternative diagnoses. Patients with ARDS should undergo Legionella-specific testing, and if Legionella is determined to be the causative organism, early VV-ECMO should be considered in patients with refractory hypoxemia given reported high survival rates.

The Use of Impella 5.5 Reduces Pulmonary Vascular Resistance as Bridge to Heart Transplant in a Pediatric Patient.

This case report explores the successful use of the Impella 5.5 (Abiomed Inc., Danvers, MA) device in a 22 kg, 0.89 body surface area (BSA) pediatric patient with longstanding dilated cardiomyopathy and elevated pulmonary vascular resistance. The article details the device selection, management, and outcome demonstrating the feasibility and potential benefits of the Impella 5.5 as a device within the pediatric population.

Impact of time of Day on Surgical Outcomes after Lung Transplantation (Night-time lung transplant).

BACKGROUND: Surgical outcomes have been linked to the technical and cognitive abilities of an exhausted surgical team. In parallel, advancements in preservation have led to the proposal of daytime lung transplants. We sought to investigate whether time of day is associated with outcomes in lung transplants. METHODS: Data on 30,404 lung transplants from 2005 to 2021 were obtained from the United Network for Organ Sharing database. Patients were categorized based on the time of surgery with "early-hours" defined as donor cross-clamp between 10PM and 3AM, and Cox regression models for 90-day and long-term mortality were made to assess the risk according to time of transplant and covariates. Additionally, the Cox modeling was repeated with donor cross-clamp and the estimated reperfusion time of day as continuous functions. RESULTS: Among 30,404 transplants, 20.7% (6,295) were performed during "early-hours". No significant difference was found between the two groups in unadjusted 90-day and long-term mortality (log-rank, p=0.176 and 0.363), and results were unchanged when adjusting for covariates (P=0.233 and 0.738). However, when examining donor cross-clamp time and reperfusion time as continuous variables in separate multivariable analyses, we observed significant associations with 90-day mortality (P=0.002 and 0.022). Notably, lower mortality rates were observed for donor clamp-times between 8AM to 1PM and estimated reperfusion times between 1PM to 6PM. CONCLUSIONS: Although binary categorizations of the time of day of lung transplants did not show a significant impact on short- or long-term survival, continuous-time analyses demonstrated certain times during the day were associated with favorable short-term survival.

Surgically implanted endovascular, microaxial left ventricular assist device: A single institution study.

Objective: The Impella 5.5 (Abiomed, Inc), a surgically implanted endovascular microaxial left ventricular assist device, is increasingly used worldwide and there have been more than 10,000 implants. The purpose of this study is to describe a large-volume, single-center experience with the use of the Impella 5.5. Methods: Data were obtained retrospectively from patients supported with the Impella 5.5 implanted at our institution from May 1, 2020, to December 31, 2022. Demographic, operative, and postoperative outcomes for each group are described. Results are reported in median (interquartile range) or n (%). The entire cohort was divided into 5 main groups based on the intention to treat at the time of the Impella 5.5 implantation: (1) patients who had a planned Impella 5.5 implanted at the time of high-risk cardiac surgery; (2) patients with cardiogenic shock; (3) patients bridged to a durable left ventricular assist device; (4) patients bridged to transplant; and (5) patients with postcardiotomy shock who received an unplanned Impella 5.5 implant. Results: A total of 126 patients were supported with the Impella 5.5. Overall survival to device explant was 76.2%, with 67.5% surviving to discharge. Midterm survival was assessed with a median follow-up time of 318 days and demonstrated an overall survival of 60.3% and a median of 650 days (549-752). Conclusions: Outcomes after using the Impella 5.5 are variable depending on the indication of use. Patient selection may be of utmost importance and requires further experience with this device to determine who will benefit from insertion.

Percutaneous decannulation reduces procedure length and rates of groin wound infection in patients on venoarterial extracorporeal membrane oxygenation.

Objective: Open decannulation from femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) carries high risk of morbidity, including groin wound infection. This study evaluated the impact of percutaneous decannulation on rates of groin wound infection in patients decannulated from femoral VA-ECMO. Methods: Between January 1, 2022, and April 30, 2023, 47 consecutive patients received percutaneous femoral VA-ECMO and survived to decannulation. A percutaneous suture-mediated closure device was used for decannulation in patients with relatively smaller arterial cannulas. Patients with larger arterial cannulas or unsuccessful percutaneous closures underwent surgical cutdown and repair of the femoral artery. The primary outcome was arterial site wound infection following decannulation. Results: Among the 47 patients who survived to decannulation from VA-ECMO, 21 underwent percutaneous decannulation and 27 underwent surgical cutdown. One patient underwent 2 VA-ECMO runs, one with percutaneous decannulation and one with surgical cutdown. Percutaneous decannulation was attempted in 22 patients, with 21 of 22 (95.5%) success rate. Decannulation procedure length was significantly shorter in the percutaneous group (79 minutes vs 148 minutes, P = .0001). The percutaneous group had significantly reduced rates of groin wound complications (0% vs 40.7%, P = .001) and groin wound infections (0% vs 22.2%, P = .03) when compared with the surgical cutdown group. Three patients (14.3%) in the percutaneous group experienced vascular complications, including pseudoaneurysm at the distal perfusion catheter site and nonocclusive thrombus of the common femoral artery. Conclusions: Percutaneous decannulation may reduce decannulation procedure length and rate of groin wound infection in patients who survive to decannulation from VA-ECMO.

Management of severe tricuspid valve regurgitation due to ruptured papillary muscle in a patient with mediastinitis early after heart transplant.

Objective: Even though severe tricuspid regurgitation is not uncommon after cardiac transplantation, primary severe tricuspid regurgitation is rare. We present such a case with additional complexities. Methods: The patient was 44-year-old man with a HeartWare durable left ventricular assist device (Heartware Inc) who received a temporary right ventricular assist device (RVAD) with a ProtekDuo cannula (LivaNova Inc USA) for refractory ventricular fibrillation and underwent a heart transplant as United Network for Organ Sharing Status 1, in the presence of partially compensated cardiogenic shock, renal failure. Given complex re-operative surgery in a volume-overloaded patient with unknown pulmonary vascular resistance, an RVAD cannula was preserved and re- inserted during cardiac transplant. Postoperatively he required hemodialysis, had severe primary tricuspid regurgitation discovered after RVAD removal and developed Enterobacter mediastinitis. He underwent complex tricuspid valve repair for flail tricuspid leaflet due to ruptured papillary muscle likely due to RVAD cannula injury, after multiple mediastinal washouts and was followed by delayed chest reconstruction. Results: The patient is doing well, 6 months after discharge to home, asymptomatic, without re-admissions, on renal recovery path, with no tricuspid regurgitation and good biventricular function. Conclusions: Replacing the tricuspid valve in presence of hemodialysis catheter, immunosuppression and mediastinitis could be high risk for endocarditis. Even though we have short-term follow-up, tricuspid valve repair can be an effective way of managing primary severe regurgitation especially when there is a desire or need to avoid valve replacement.

First Report of Proton Beam Therapy in a Patient With a Left Ventricular Assist Device.

A 77 year old man previously implanted with a HeartMate II left ventricular assist device (LVAD) as destination therapy and an implantable cardioverter defibrillator presented with a left upper lobe squamous cell lung cancer. Oncology determined that proton beam therapy was indicated for treatment, and a multidisciplinary team of radiation physicists, radiation oncologists, and LVAD providers developed a protocol to proceed safely. He was successfully treated with combined proton beam radiation therapy and reduced dose chemotherapy. This case demonstrates feasibility and considerations of proton beam therapy for malignancy relevant to patients with implantable cardiac devices including LVADs.

Lung transplantation long-term survival is worse in patients who have undergone previous cardiac surgery.

OBJECTIVES: Approximately 10% of lung transplant recipients have had previous cardiothoracic surgery. We sought to determine if previous surgery affects outcomes after lung transplant at a national level. METHODS: The United Network for Organ Sharing database was analysed from 2005 to 2019 to include adult patients who underwent lung transplant who had previous cardiac surgery and previous thoracic surgery. T-test and chi-squared analysis were used to compare perioperative outcomes. Long-term survival comparison was performed using the Kaplan-Meier method in an unadjusted and propensity-matched analysis. RESULTS: Out of 24 784 lung transplants, 691 (2.7%) had previous cardiac surgery and 1321 (6.5%) had previous thoracic surgery. Operative mortality was worse in previous cardiac surgery [42 (6.1%)] versus no previous cardiac surgery [740 (3.1%), P < 0.001] and in previous thoracic surgery [65 (4.9%)] versus no previous thoracic surgery [717 (3.1%), P < 0.001]. The previous thoracic surgery group had more primary graft failure and treated rejection during the first-year post-transplant. There was no difference in stroke, dialysis, intubation and extracorporeal membrane oxygenation at 72 h. Long-term survival was significantly worse for lung transplant patients who had undergone previous cardiac surgery (median 3.8 vs 6.3 years, P < 0.001) due to an increase in cardiovascular deaths (P = 0.008) and malignancy (P = 0.043). However, there was no difference in previous thoracic surgery (median 6.6 vs 6.1 years, P = 0.337). CONCLUSIONS: Previous cardiac surgery prior to lung transplant results in worse survival related to cardiovascular death and malignancies. Previous thoracic surgery worsens perioperative outcomes but does not affect long-term survival.

Induction of CD4(+)CD25(+) T regulatory cells with CD103 depletion.

BACKGROUND: M290SAP, a murine CD103 antibody conjugated with the immunotoxin saporin, has been found to induce the indefinite acceptance of transplanted pancreatic islets in mice. We sought to understand the underlying mechanism of this alloacceptance, particularly with respect to the CD4 CD25 T regulatory phenotype. METHODS: In this study, we established the kinetics of M290SAP and evaluated the requirement of alloantigen for the induction and maintenance of CD4 CD25 T regulatory cells (Tregs). Naive C57BL/6 mice were treated with several doses of M290SAP with and without donor-specific blood or splenocytes. Blood and spleens were collected at specific time points and underwent FACS analysis. RESULTS: M290SAP significantly depleted CD103 cells and induced the up-regulation of CD4 CD25 T regulatory population in spleen cell preparations. The combination of alloantigen in the form of donor-specific blood or splenocytes, with M290SAP, further induced the up-regulation of CD4 CD25 Tregs in the spleen compared with either M290SAP alone or alloantigen alone. The generation of CD4 CD25 cells and the depletion of CD103 cells reached a maximum at 7 d and by 3 wk CD103 and CD4 CD25 T regulatory cell populations returned to baseline. When multiple antigenic challenges were administered, the splenic CD4 CD25 cell population was again up-regulated and persisted for 3 wk. CONCLUSION: Our data confirm that M290SAP induces the generation of the CD4 CD25 T regulatory phenotype in spleens of naïve mice. Alloantigen further enhances and rejuvenates the CD4 CD25 cell population in mice treated with M290SAP.

Does Donor Age and Double Versus Single Lung Transplant Affect Survival of Young Recipients?

BACKGROUND: In an effort to expand the donor pool for lung transplants, numerous studies have examined the use of advanced age donors with mixed results, including decreased survival among younger recipients. We evaluated the impact of the use of advanced age donors and single versus double lung transplantation on posttransplant survival. METHODS: The United Network for Organ Sharing database was retrospectively queried between January 2005 and June 2014 to identify lung transplant patients aged at least 18 years. Patients were stratified by recipient age 50 years or less, donor age 60 years or more, and single versus double lung transplantation. Overall survival was assessed using the Kaplan-Meier method. Multivariable survival analysis was performed using a Cox proportional hazards model. RESULTS: In all, 14,222 lung transplants were performed during the study period. With univariate analysis, donor lungs aged 60 years or more were associated with slightly worse 5-year survival (44% versus 52%; p < 0.001). Among recipients aged more than 50 years, this trend was not present in the multivariate model (hazard ratio 1.23, p = 0.055). Among recipients aged 50 years or more, receiving older donor lungs showed worse survival with the use of single lung transplant (5-year survival 15% versus 50%, p = 0.01). No significant difference in survival between young and old donors was seen when double lung transplant was performed (p = 0.491). Cox proportional hazards model showed a trend toward interaction between single lung transplantation and older donors (hazard ratio 2.36, p = 0.057). CONCLUSIONS: Reasonable posttransplant outcomes can be achieved with use of advanced age donors in all recipient groups. Double lung transplantation should be performed when older donors (age more than 60) are used in young recipients (age 50 or less).