Use of Extracorporeal Membrane Oxygenation as Bridge to Replacement Therapies in Cardiogenic Shock: Insights From the Extracorporeal Life Support Organization.

BACKGROUND: There has been increasing use of extracorporeal membrane oxygenation (ECMO) as bridge to heart transplant (orthotopic heart transplant [OHT]) or left ventricular assist device (LVAD) over the last decade. We aimed to provide insights on the population, outcomes, and predictors for the selection of each therapy. METHODS: Using the Extracorporeal Life Support Organization Registry between 2010 and 2019, we compared in-hospital mortality and length of stay, predictors of OHT versus LVAD, and predictors of in-hospital mortality for patients with cardiogenic shock that were bridged with ECMO to OHT or LVAD. One hundred sixty-seven patients underwent LVAD versus 234 patients who underwent OHT. RESULTS: The overall use of ECMO has increased from 1.7% in 2010 to 22.2% in 2019. Mortality was similar between groups (LVAD: 28.7% versus OHT: 29.1%) while length of stay was longer for OHT (LVAD: 49.6 versus OHT: 59.5 days, P=0.05). Factors associated with OHT included prior transplant (odds ratio [OR]=31.26 [CI, 3.84-780.5]), use of a temporary pacemaker (OR=6.5 [CI, 1.39-50.15]), and increased use of inotropes on ECMO (OR=3.77 [CI, 1.39-11.07]), whereas LVAD use was associated with weight (OR=0.98 [CI, 0.97-0.99]), cardiogenic shock presentation (OR=0.40 [CI, 0.21-0.78]), previous LVAD (OR=0.01 [CI, 0.0001-0.22]), respiratory failure (OR=0.28 [CI, 0.11-0.70]), and milrinone infusion (OR=0.32 [CI, 0.15-0.67]). Older age (OR=1.07 [CI, 1.02-1.12]), cannulation bleeding (OR=26.1 [CI, 4.32-221.3]), and surgical bleeding (OR=6.7 [CI, 1.26-39.9]) in patients receiving LVAD and respiratory failure (OR=5 [CI, 1.17-23.1]) and continuous renal replacement therapy (OR=3.82 [CI, 1.28-11.9]) in patients receiving OHT were associated with increased mortality. CONCLUSIONS: ECMO use as a bridge to advanced therapies has increased over time, with more patients undergoing LVAD than OHT. Mortality was equal between the 2 groups while length of stay was longer for OHT.

Expert Consensus Paper: Lateral Thoracotomy for Centrifugal Ventricular Assist Device Implant.

BACKGROUND: The increasing prevalence of heart failure has led to the expanded use of left ventricle assist devices (VADs) for end-stage heart failure patients worldwide. Technological improvements witnessed the development of miniaturized VADs and their implantation through less traumatic non-full sternotomy approaches using a lateral thoracotomy (LT). Although adoption of the LT approach is steadily growing, a lack of consensus remains regarding patient selection, details of the surgical technique, and perioperative management. Furthermore, the current literature does not offer prospective randomized studies or evidence-based guidelines for LT-VAD implantation. METHODS: A worldwide group of LT-VAD experts was convened to discuss these key topics openly. After a PubMed search and review with all authors, a consensus was reached and an expert consensus paper on LT-VAD implantation was developed. RESULTS: This document aims to guide clinicians in the selection of patients suitable for LT approaches and preoperative optimization. Details of operative techniques are described, with an overview of hemisternotomy and bilateral thoracotomy approaches. A review of the best surgical practices for placement of the pump, inflow cannula, and outflow graft provides advice on the best surgical strategies to avoid device malpositioning while optimizing VAD function. Experts' opinions on cardiopulmonary bypass, postoperative management, and approaches for pump exchange and explant are presented. This review also emphasizes the critical need for multidisciplinary teams and specific training. CONCLUSIONS: This expert consensus review provides a compact guide to LT for VAD implantation, from patient selection through intraoperative tips and postoperative management.

Invasive fungal infection after heart transplantation: A 7-year, single-center experience.

BACKGROUND: Invasive fungal infections (IFIs) are an infrequent but major complication of heart transplantation (HT). We sought to describe the epidemiology at our institution. METHODS: A prospective cohort study of 159 heart transplant recipients was performed from June 2005 to December 2012. IFIs were defined by European Organization for Research and Treatment of Cancer/Mycoses Study Group criteria. RESULTS: By univariate analysis, Hispanic ethnicity was associated with IFI (P=.01, odds ratio [OR] 7.0, 95% confidence interval [CI] 1.7-27.9). Subsequently, a multivariate logistic regression was performed adjusting for Hispanic ethnicity, age, and gender. Seventeen IFIs were identified, occurring at a median 110 days post HT (interquartile range: 32-411 days). Five IFIs (29% of IFIs and 3.1% of all HT) occurred during the HT hospitalization, with 13 IFIs during the first year (incidence 8.2%). CONCLUSIONS: The cumulative incidence was 10.7%. IFIs were associated with pre- and post-HT vancomycin-resistant Enterococcus colonization and/or infection, post-HT renal replacement therapy, anti-thymocyte globulin induction, and antibody-mediated rejection. There were no associations with diabetes mellitus, desensitization, 2R/3R cellular rejection, treatments for rejection, re-operation, neutropenia, or cytomegalovirus infection. IFIs were associated with death (P=.02, OR 3.9, 95% CI 1.3-12.1) and 1-year mortality (P<.001, OR 9.0, 95% CI 2.3-35.7), but not 3-year mortality. Associations with Hispanic ethnicity must be validated. Optimal strategies for risk reduction and prophylaxis remain undefined.

Update on Antibiotic Prophylaxis for Genitourinary Procedures in Patients with Artificial Joint Replacement and Artificial Heart Valves.

Infection of artificial joint replacements and heart valves is an uncommon but serious complication encountered anytime after the implantation of these prostheses. It is known that bacteremia can lead to infection of a prosthetic device. However, there is no strong evidence to correlate urologic procedures with the development of periprosthetic joint infection or prosthetic valve endocarditis. Therefore, antibiotic prophylaxis for the prevention of endocarditis is not recommended in patients undergoing urologic procedures. However, guidelines regarding prophylaxis to prevent infection of an artificial joint in the setting of a genitourinary procedure are more varied.

Paravalvular regurgitation after conventional aortic and mitral valve replacement: A benchmark for alternative approaches.

OBJECTIVE: Paravalvular regurgitation is a known complication after transcatheter and sutureless aortic valve replacement. Paravalvular regurgitation also may develop in patients undergoing percutaneous mitral valve replacement. There are few studies on contemporary surgical valve replacement for comparison. We sought to determine the contemporary occurrence of paravalvular regurgitation after conventional surgical valve replacement. METHODS: We performed a single-center retrospective database review involving 1774 patients who underwent valve replacement surgery from April 2004 to December 2012: aortic in 1244, mitral in 386, and combined aortic and mitral in 144. Follow-up echocardiography was performed in 73% of patients. Patients with endocarditis were analyzed separately from noninfectious paravalvular leaks. Statistical comparisons were performed to determine differences in paravalvular regurgitation incidence and survival. RESULTS: During follow-up, 1+ or greater (mild or more) paravalvular regurgitation occurred in 2.2% of aortic cases and 2.9% of mitral cases. There was 2+ or greater (moderate or more) paravalvular regurgitation in 0.9% of aortic and 2.2% of mitral cases (P = .10). After excluding endocarditis, late noninfectious regurgitation 2+ or greater was detected in 0.5% of aortic and 0.4% of mitral cases (P = .93); there were no reoperations or percutaneous closures for noninfectious paravalvular regurgitation. CONCLUSIONS: In an academic medical center, the overall rate of paravalvular regurgitation is low, and late clinically significant noninfectious paravalvular regurgitation is rare. The benchmark for paravalvular regurgitation after conventional valve replacement is high and should be considered when evaluating patients for transcatheter or sutureless valve replacement.

Overcoming reporting challenges: How to display, summarize, and model late reintervention outcomes, follow-up, and vital status information after surgery for atrial fibrillation.

BACKGROUND: Postsurgical late reinterventions for atrial fibrillation (AF) include cardioversions (CV) or catheter ablations (CA). Commonly used methods for reporting and modeling the frequency and timing of CA or CV have well-known shortcomings. OBJECTIVE: The purpose of this study was to present intuitive and robust methods to visualize, summarize, and model late reinterventions type/timing and vital status simultaneously. METHODS: We present (1) the SMART plot (Summary of Mortality And Outcomes Reported Over Time); (2) the reintervention mean cumulative function (MCF); and (3) the proportional means model and the proportional rates model. We illustrate these methods in 3 groups: patients age ≤60 years, 60-75 years (reference), and >75 years who underwent surgical AF ablation. RESULTS: Patients age >75 years had a significantly lower MCF of CVs (hazard ratio [HR] 0.50, P <.001). MCF for CAs was not significantly lower for patients age >75 years (HR 0.57, P = .13). For combined reinterventions (CV or CA), the age group >75 years had a significantly lower MCF (HR 0.51, P <.001). There were no significant differences in late CV or CA reintervention patterns for patients age ≤60 years. CONCLUSION: The methods presented provide a comprehensive framework for displaying, summarizing, and modeling repeated late reinterventions after surgical AF ablation. Other areas of application are described, further emphasizing the potential for immediate use.

Mortality while waiting for aortic valve replacement.

BACKGROUND: Severe symptomatic aortic stenosis (AS) is associated with high mortality without intervention. The impact of waiting time for aortic valve replacement (AVR), either surgically or transcatheter, has not been reported. METHODS: From January 2008 to December 2012, we identified 1,005 patients with severe symptomatic AS. AVR was recommended for 823 patients (82%). Of these 823 patients, 721 (87.6%) underwent AVR. We modeled overall survival (OS) since AVR recommendation or intervention date using Cox and multistate models. RESULTS: Overall, the median (first, third quartiles) waiting time until operation was 2.9 (1.3, 5.1) weeks. Mortality at these times was lower (p<0.001) in the AVR group (1.2%, 0.3%, 1.7%, respectively) than in the group that did not receive AVR (6.9%, 2.9%, 9.8%, respectively). Thirty-day mortality after AVR was 3.9% (3.2% surgical AVR [SAVR] and 7.0% transcatheter AVR [TAVR]). In patients receiving AVR, waiting time was not associated with increased mortality. Mortality while waiting for AVR was 3.7% and 11.6% at 1 and 6 months, respectively. Mortality while waiting for TAVR was higher than that for SAVR (1-, 6-, and 12-month mortality of 3.7%, 8.0%, and 9.6%, respectively, in SAVR group and 3.8%, 23.3%, and 27.5%, respectively, in TAVR group; p<0.001). CONCLUSIONS: Some patients do not receive AVR in a timely fashion, and prolonged waiting time for AVR is associated with mortality greater than the AVR operative mortality. Although waiting time was not associated with poor operative outcomes after AVR, many patients may die while waiting for AVR. Patients should receive AVR on a semiurgent, not elective, basis.

A simple approach to mitral valve repair: posterior leaflet height adjustment using a partial fold of the free edge.

OBJECTIVES: Multiple techniques have been used to repair degenerative mitral valve prolapse with leaflet elongation, without creating systolic anterior motion. We describe a simple, reproducible, measured technique to guide repair. METHODS: From January 2010 to July 2012, 171 patients underwent mitral valve repair; 128 (75%) with Carpentier type II prolapse. For 48 patients (37.5%), the resected posterior leaflet free edge was partially folded to restore the normal 2:1 ratio of the A2 and P2. All patients underwent complete ring annuloplasty sized to the height of A2. RESULTS: The preoperative A2/P2 ratio was 1.5 ± 0.5. After repair, the A2/P2 ratio was 1.9 ± 0.3 and 2.0 ± 0.3 in the no fold and partial fold groups, respectively (P = .57). The ring sizes were larger in the partial fold group (P < .001) because the A2 height was larger (P = .001). No obstructive systolic anterior motion was present. Of the 171 patients, 91.4% had grade 4+ preoperative mitral regurgitation, with no 3 or 4+ mitral regurgitation during follow-up. At the last follow-up visit, grade 2+ mitral regurgitation was observed in 5% of the patients. No 30-day mortalities or reoperations occurred. CONCLUSIONS: Partial fold of the posterior leaflet free edge is a simple technique to restore the normal 2:1 ratio of A2/P2 with a ring size determined by the A2 height. Using just the A2 height, mitral surgeons can reproducibly repair the posterior leaflet prolapse, choose the appropriate ring size, and avoid more complex leaflet reconstruction or judgment of the neochord length.

Chest wall resection and reconstruction: a true thoracoscopic approach.

We set out to perform resection of a chest wall mass with subsequent reconstruction using a pure thoracoscopic approach. Using video-assisted thoracic surgery via a three-incision approach, we successfully removed an 8.5 × 3.5-cm specimen en bloc. We then reconstructed the chest wall with 2-mm polytetrafluoroethylene. A total thoracoscopic approach to chest wall resection and reconstruction represent an additional option in this area of thoracic surgery. This approach avoids some of the drawbacks of more invasive procedures. This report outlines a totally thoracoscopic approach that we feel represents a safe and viable option for patients requiring chest wall resection and reconstruction.