Antegrade or Retrograde Cerebral Perfusion in Ascending Aorta and Hemiarch Surgery? A Propensity-Matched Analysis.

BACKGROUND: Over the years, numerous options have been proposed for surgical management of ascending aorta and aortic arch pathology in an attempt to minimize postoperative morbidity and probability of death. We present a propensity score-matching analysis of 259 patients from a single unit who were operated on under deep hypothermic arrest with retrograde cerebral perfusion (DHCA/RCP) or moderate hypothermic circulatory arrest with selective antegrade cerebral perfusion (via common carotid artery) (MHCA/ACP). METHODS: Between 2006 and 2014 a total of 259 consecutive patients underwent ascending aorta and hemiarch correction under HCA. DHCA/RCP and MHCA/ACP were performed on 207 and 52 patients, respectively. Baseline patient characteristics accounted for in the propensity matching were age, sex, acute aortic dissection, emergency operation, re-operation, preoperative hemodynamic instability, preoperative kidney injury, and CA time. After propensity scoring 40 pairs (80 patients) were successfully matched (p = 0.732). Outcomes were defined as the incidence of postoperative neurologic complications, 30-day mortality, and all-cause midterm mortality. RESULTS: Surgical procedure that involved the MHCA/ACP technique was associated with 76.5% decreased risk (risk ratio, 0.235; 95% CI, 0.079 to 0.699) of postoperative neurologic complications (p = 0.009). In addition to MHCA/ACP in surgical procedure for acute aortic dissection a relevant trend was established for 30-day mortality (risk ratio, 0.333; 95% CI, 0.09 to 1.23). For midterm all-cause mortality, MHCA/ACP modestly decreased the number of deaths (p = 0.0456) in comparison with the DHCA/RCP technique. CONCLUSIONS: MHCA/ACP in aortic arch surgical procedure is associated with a decreased risk of all types of neurologic complications and a trend toward decreased 30-day and midterm mortality in comparison with DHCA/RCP.

Inhaled nitric oxide plus iloprost in the setting of post-left assist device right heart dysfunction.

BACKGROUND: Pulmonary hypertension and right ventricular (RV) dysfunction may complicate the implantation of a left ventricular assist device (LVAD). We examined whether inhaled vasodilators can sufficiently reduce RV afterload, avoiding the need for temporary RV mechanical support. METHODS: The study includes 7 patients with RV dysfunction after LVAD insertion. Treatment consisted of inotropes, inhaled nitric oxide (10 ppm), and iloprost (10 µg) in repeated doses. Full hemodynamic profile was obtained before inhalation, during administration of inhaled NO alone (before and after iloprost), as well as after the first two doses of inhaled iloprost. Tricuspid annular velocity was estimated at baseline and before and after adding iloprost. RESULTS: There was a statistically significant reduction in pulmonary vascular resistance (PVR), mean pulmonary artery pressure (MPAP), RV systolic pressure, and pulmonary capillary wedge pressure, and a considerable increase in LVAD flow, LV flow rate index, and tricuspid annular velocity at all points of evaluation versus baseline. By the end of the protocol, MPAP/mean systemic arterial pressure, and PVR/systemic vascular resistance ratios were reduced by 0.17±0.03 (95% confidence interval, 0.10 to 0.25, p=0.001) and 0.12±0.025 (95% confidence interval, 0.06 to 0.18; p=0.003), respectively. The tricuspid annular velocity increased by 2.3±0.18 cm/s (95% confidence interval, 1.83 to 2.73 cm/s; p<0.001). Pairwise comparisons before and after iloprost showed an important decrease in PVR (p=0.022), MPAP (p=0.001), pulmonary capillary wedge pressure (p=0.002), and RV systolic pressure (p<0.001), and a rise in tricuspid annular velocity (p=0.008). CONCLUSIONS: Inhaled vasodilators mainly affected the pulmonary vasculature. Combination treatment with inhaled NO and iloprost sufficiently decreased PVR and MPAP on the basis of an additive effect, improved RV function, and avoided the need for RV assist device.

Thrombosis of the ascending aorta during mechanical circulatory support in a patient with cardiogenic shock.

Cardiogenic shock after percutaneous coronary intervention (PCI) is a life-threatening complication and is most often related to abrupt vessel closure. We present the case of a patient who developed cardiogenic shock after PCI and was supported with intra-aortic balloon counterpulsation and the Levitronix CentriMag short-term mechanical circulatory support. He was evaluated for implantation of a ventricular assist device as bridge-to-transplantation. Preoperative transesophageal echocardiography revealed a massive thrombus of the aortic root and ascending aorta despite optimal anticoagulation regimen. The patient succumbed due to multiorgan failure.

Reoperations in adults after correction of tetralogy of Fallot.

Adults with congenital heart diseases are an increasing patient population. Since the first successful palliative procedure in 1945 (Blalock and Tausing, JAMA 128: 189-194, 1945) and first corrective operation in 1955 (Lillehei et al., Ann Surg 142: 418, 1955) patients with Tetralogy of Fallot, which is the most common cyanotic CHD, have had excellent long term results and good quality of life. Over the long term, these patients are under risk of sudden death because of arrhythmias and congestive heart disease caused by tricuspid regurgitation, pulmonary regurgitation, ventricular septal defect, right ventricular outflow tract obstruction.

Gigantic retroperitoneal hematoma as a complication of anticoagulation therapy with heparin in therapeutic doses: a case report.

INTRODUCTION: Spontaneous retroperitoneal hemorrhage is a distinct clinical entity that can present as a rare life-threatening event characterized by sudden onset of bleeding into the retroperitoneal space, occurring in association with bleeding disorders, intratumoral bleeding, or ruptures of any retroperitoneal organ or aneurysm. The spontaneous form is the most infrequent retroperitoneal hemorrhage, causing significant morbidity and representing a diagnostic challenge. CASE PRESENTATION: We report the case of a patient with coronary artery disease who presented with transient ischemic attack, in whom anticoagulant therapy with heparin precipitated a massive spontaneous atraumatic retroperitoneal hemorrhage (with international normalized ratio 2.4), which was treated conservatively. CONCLUSION: Delay in diagnosis is potentially fatal and high clinical suspicion remains crucial. Finally, it is a matter of controversy whether retroperitoneal hematomas should be surgically evacuated or conservatively treated and the final decision should be made after taking into consideration patient's general condition and the possibility of permanent femoral or sciatic neuropathy due to compression syndrome.

Risk factor analysis in pediatric heart transplantation.

BACKGROUND: Steady assessment of risk factors will enable identification of patients at higher risk for post-transplant death, and may thus improve organ utilization and outcomes. In this study we aimed to identify the risk factors of mortality in pediatric heart transplantation. METHODS: Between November 1989 and February 2004, there were 116 orthotopic heart transplantations performed in patients <18 years of age at our institution. RESULTS: The 30-day mortality risk was 12% (dilated cardiomyopathy 7%, congenital heart disease 26%; univariate analysis: p = 0.023). The main cause of 30-day mortality was primary graft failure (36%). The late mortality rate was 31 per 1,000 person-years. The main causes of late mortality were acute rejection (44%) and cardiac allograft vasculopathy (26%). The 1-, 5-, 10- and 15-year survival rates were 85%, 77%, 65% and 53%, respectively. Male donor (odds ratio [OR] 6.33, 95% confidence interval [CI] 1.11 to 36.01) and cardiopulmonary bypass >210 minutes (OR 43.05, 95% CI 1.11 to 1,669) were risk factors for 30-day mortality. Risk factors for 1- and 5-year mortality were body weight ratio <0.8 (OR 40.36, 95% CI 3.04 to 536.47) and male donor (OR 3.36, 95% CI 1.05 to 10.75), respectively. Recipient age <1 year (OR 64.65, 95% CI 1.69 to 2,466.77) and donor-recipient body surface area mismatch of <0.9 (OR 10.58, 95% CI 1.03 to 108.25) were risk factors for 10-year mortality. CONCLUSIONS: Pediatric heart transplantation can be performed with an expectation of excellent results. Certain risk factors suggest poorer outcomes.

International normalized ratio self-management lowers the risk of thromboembolic events after prosthetic heart valve replacement.

BACKGROUND: Although prosthetic valves are durable and easy to implant, the need for lifetime warfarin-based anticoagulation restricts their exclusive usage. We investigated if anticoagulation self-management improves outcome in a single-center series. METHODS: Between 1994 and 1998, 765 patients with prosthetic valve replacements were prospectively enrolled and randomized to receive conventional anticoagulation management by their primary physician (group 1, n = 295) or to pursue anticoagulation self-management (group 2, n = 470). A study head office was implemented to coordinate and monitor anticoagulation protocols, international normalized ratios (INR), and adverse events. Patients were instructed on how to obtain and test their own blood samples and to adjust warfarin dosages according to the measured INR (target range, 2.5 to 4). RESULTS: Mean INR values were slightly yet significantly smaller in group 1 than in group 2 (2.8 +/- 0.7 vs 3.0 +/- .6, p < 0.001). Moreover, INR values of patients with conventional INR management were frequently measured outside the INR target range, whereas those with anticoagulation self-management mostly remained within the range (35% vs 21%, p < 0.001). In addition, the scatter of INR values was smaller if self-managed. Freedom from thromboembolism at 3, 12, and 24 months, respectively, was 99%, 95%, and 91% in group 1 compared with 99%, 98%, and 96% in group 2 (p = 0.008). Bleeding events were similar in both groups. Time-related multivariate analysis identified INR self-management and higher INR as independent predictors for better outcome. CONCLUSIONS: Anticoagulation self-management can improve INR profiles up to 2 years after prosthetic valve replacement and reduce adverse events. Current indications of prosthetic rather than biologic valve implantations may be extended if the benefit of INR self-management is shown by future studies with longer follow-up.

Heart transplantation after Fontan procedure in adults.

Complex congenital heart disease is the cause for 1.5%-2.4% of heart transplantations in adults. Indications for heart transplantation are ventricular dysfunction, failed Fontan physiology, and cyanosis. We present a 43-year-old man, 20 years after a Fontan operation by an univentricular heart, with a tricuspid atresia, L-Transposition of the Great Arteries, and high-grade subpulmonary stenosis. Persistent bleeding after successful transplantation necessitated major blood transfusions and reoperation. We reconstructed superior vena cava and vena brachiocephalica using a pericardial patch, and because of postoperative low output syndrome, he was connected to extracorporeal circulation through cannulation of femoral artery and explanted after hemodynamic stability. Heart transplantation can be successful in patients with end-stage congenital heart diseases after Fontan procedure, because of improved surgical and medical management. Challenges include limited ability to assess hemodynamics, complex anatomy, increased risk of bleeding caused by multiple prior procedures, and unique underlying pathologic states. Careful patient selection and surgical timing are essential to increase long-term survival.

Surgical repair of congenital supravalvular aortic stenosis in adult.

Supravalvular aortic stenosis is a rare congenital cardiac anomaly occurring mainly as a part of Williams-Beuren syndrome. Aortic narrowing above the level of the aortic valve causes obstruction of the left ventricular outflow tract, and a pressure gradient between the left ventricle and the aorta causes left ventricle hypertrophy. We report here a case of a 22-year-old man who underwent extended patch aortoplasty because of supravalvular aortic stenosis accompanying Williams-Beuren syndrome. He was in New York Heart Association functional class III with localized hourglass type supravalvular aortic stenosis. Related to arterial hypertension he was in a cardiac decompensation. Mean pressure gradient was 73 mm Hg and maximum gradient 104 mm Hg. Electrocardiography indicated left ventricle hypertrophy, which was also seen in x-ray, as heart enlargement. We successfully treated this patient with extended patch aortoplasty and immediate postoperative echocardiography showed reduction of gradient. Good surgical outcome of congenital supravalvular aortic stenosis in adults can be achieved with this treatment. This technique provides symmetric reconstruction of the aorta with good postoperative results and no gradient across aortic valve and aortic valve insufficiency remains, providing excellent long-term relief of localized supravalvular gradients and preservation of aortic valve competence.

Long-term experiences on cardiac retransplantation in adults.

BACKGROUND: It remains disputed whether cardiac retransplantation should be performed. This study aimed to evaluate our long-term experiences on cardiac retransplantation in adults. PATIENTS AND METHODS: Between March 1989 and December 2004, 2% (28/1290) of cardiac retransplantations were performed. RESULTS: The reasons for cardiac retransplantation were cardiac allograft vasculopathy (n=13; 47%), primary graft failure (n=11; 39%), and refractory acute rejection (n=4; 14%). The 30-day mortality risk was 29% (acute rejection: 50%; primary graft failure: 36%; cardiac allograft vasculopathy: 15%, p=0.324), compared to 8.5% for primary cardiac transplantation (p<0.001). The causes of early death were acute rejection (n=3; 37%), multiorgan failure (n=3; 37%), primary graft failure (n=1; 13%), and right ventricular failure (n=1; 13%). The late mortality rate was 96/1000 patient-years. The causes of late death were acute rejection (n=4; 50%), cardiac allograft vasculopathy (n=2; 25%), multiorgan failure (n=1; 13%), and infection (n=1; 13%). The 1-, 5-, 10-, and 15-year survival was respectively 78, 68, 54, and 38% (primary cardiac transplantation), and 46, 41, 32, and 32% (cardiac retransplantation) (p=0.003). The short-term survival for cardiac retransplantation due to cardiac allograft vasculopathy was likely better than primary graft failure and refractory acute rejection (p=0.09). CONCLUSION: The overall outcomes of cardiac retransplantation are significantly inferior to primary cardiac transplantation. Cardiac retransplantation should be only performed for selected patients.

Heart transplantation in children: clinical outcomes in a single center.

BACKGROUND: Despite being accepted as the best treatment for end-stage heart diseases, the long-term benefit of heart transplantation in children remains a matter of controversial debate. This study aimed to evaluate our clinical experience with heart transplantation in children. METHODS: From March 1989 to December 1999, 93 consecutive orthotopic heart transplantations in children (less than 18 years of age) were performed at the Department of Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW in Bad Oeynhausen, Germany. Clinical data were retrieved from a computerized database. Follow-up information was 100% completed. RESULTS: The main indications for heart transplantation were dilated cardiomyopathy (68%) and congenital heart disease (31%). Early mortality risk was 14% +/- 3.6%. Primary graft failure (39%) was the main cause of early death. Total follow-up time was 694 patient-years (mean, 104.1 +/- 42.8 months). Twenty-three patients died during follow-up, resulting in 33 of 1,000 patient-years of late mortality rate. Acute rejection (43%) and allograft vasculopathy (26%) were attributed to late mortality. The 1-, 5-, 10-, and 15-year survival was 83%, 74%, 63%, and 50%, respectively. Recipient age less than one year (p = 0.02) and ischemia time greater than 300 minutes (p = 0.04) were associated with decreased survival. Social activities at the end of follow-up were school (69%), working (19%), and at home (12%). CONCLUSIONS: Heart transplantation is a rational and durable treatment option for children with end-stage heart diseases. The long-term outcomes and quality of life after heart transplantation in children are encouraging.

New method for sternal closure after vacuum-assisted therapy in deep sternal infections after cardiac surgery.

The treatment of nonhealing and infected sternotomies after cardiac surgery is a challenging task with increased rates of mortality and morbidity, as well as high costs. A local vacuum therapy (ie, the vacuum-assisted closure system) permits the treatment of deep sternal infections due to continuous aspiration and a sealed dressing that stimulates granulation tissue formation. Aggressive vacuum-assisted closure treatment of the sternum in postoperative deep wound infection enhances sternal preservation and the speed of potential rewiring. After some weeks of vacuum-assisted closure therapy, a complete preparation of the substernal structures is necessary. In this context, laceration of the right ventricle is a rare but life-threatening complication. We describe a new technique for sternal closure after vacuum-assisted wound treatment using Nitinol clips (Praesidia, Bologna, Italy), which can prevent these severe complications. Without any preparation of the substernal tissue the clips can be inserted in the parasternal space with consecutive proper stabilization of the sternum. This new method represents an easy, low-cost and complication-free procedure.

Heart transplantation in adults with congenital heart disease: experience with 15 patients.

End-stage congenital heart disease (CHD) is an important indication for pediatric heart transplantation (HTx) as well as transplantation in adult populations. The purpose of this retrospective analysis was to compare the survival rate of adults who underwent HTx for end-stage CHD with those who underwent HTx for other causes. To find out whether HTx is a viable therapeutic option for adult patients with preoperated CHD, data from 15 adult patients with different forms of CHD, who had previously undergone different corrective and palliative procedures, were retrospectively analyzed and compared with the HTx data of 1400 adult patients (>15 years old) whose indications for HTx were other than end-stage CHD. From 1989 to 2005, 15 adult patients (eight men/seven women) were given transplantation for end-stage CHD. Ten patients had been preoperated once, five patients twice. Their mean age was 34.06 +/- 3.9 years. In five cases, patients had development of acute renal failure. One female patient died 40 days after surgery, after having a cerebral infarction; one male patient died 4 years after HTx for OKT 3 monoclonal antibody-resistant rejection; and two patients died as the result of multiple organ failure at 4 days and 30 days after HTx, respectively; 11 patients are still alive. The cumulative survival rate at 1 year is 80% versus 80% in patients given transplantation for noncongenital indications. Heart transplantation in adults with end-stage CHD can be performed with a good long-term prognosis. Previous palliative operations do not affect outcome after HTx.

Outcome of heart transplantation in pediatric recipients: experience in 128 patients.

The purpose of this study was to review the outcome of pediatric heart recipients with uncorrectable congenital heart disease, failed corrective procedures, or intractable acquired cardiomyopathy. Between 1988 and 2005, cardiac transplantations were performed in 128 pediatric patients (59 girls and 69 boys) at the Heart-Center North-Rhine-Westphalia. Their ages varied between 1 week and 18 years (mean, 7.6 +/- 6.2 years). Underlying diseases were dilative cardiomyopathy in 93 cases and uncorrectable congenital heart disease in 35 cases. We diagnosed and observed 130 episodes of acute rejection in 85 patients (65.3% of patients had an acute rejection during the observation period); 71 patients were treated efficiently with steroid-pulse therapy. Monoclonal antibody OKT3 was administrated in 14 patients because of steroid-resistant acute donor organ rejection. Five of those 14 patients survived. The cumulative survival was 88% after 1 year and 68% after 10 years for all patients. Orthotopic heart transplantation is the ultimate treatment option for children with end-stage heart disease and shows an acceptable perioperative mortality rate as well as good long-term results.

Acute fulminant myocarditis in children and adolescents: the role of mechanical circulatory assist.

We report children and adolescents in fulminant myocarditis undergoing prolonged circulatory support with different assist devices. Between 1994 and 2004, seven children and adolescents (aged 7-18 years, mean age 13.5 years) were treated with VADs (5 Thoratec, 1 Medos, 1 Novacor) for circulatory support. Three patients underwent left ventricular support; biventricular support was necessary in four patients. Four patients (three left VADs, one bi-VAD) could be successfully bridged to heart transplantation after a mean support time of 163 days (56-258 days). One 7-year-old girl (Medos-BVAD) died after a support time of 11 days because of irreversible multiorgan failure. One 18-year-old patient was successfully weaned from Thoratec BVAD after 66 days with complete recovery of left ventricular function. As good markers, atrial and brain natriuretic peptides were found which reached normal values after recovery of myocardial function. A 15-year-old girl is still on the device. In children or adolescents with irreversible shock in fulminant myocarditis with an anticipated mortality of 100%, both successful bridging to heart transplantation and successful bridging to recovery are possible. Young patients with fulminant myocarditis should be rapidly transferred to a clinic with a mechanical circulatory support program to offer this life-saving option.