Upgrading extra corporeal life support to ECMELLA using Impella 5.0 in rescued INTERMACS 1 patients, lactate level matters!

Background: Venoarterial extra corporeal life support (ECLS) is the treatment of choice of Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) class 1 patients, but left ventricle (LV) overload is a complication of ECLS. Unloading the LV by adding Impella 5.0 to ECLS in Impella used in combination with venoarterial extracorporeal membrane oxygenation (ECMELLA) configuration is recommended only in patients with acceptable prognosis. We investigated whether serum lactate level, a simple biological parameter, could be used as a marker to select candidates for bridging from ECLS to ECMELLA. Methods: Forty-one consecutive INTERMACS 1 patients under ECLS were upgraded to ECMELLA using Impella 5.0 pump implantation to unload the LV and were followed-up for 30 days. Demographic, clinical, imaging, and biological parameters were collected. Results: The time between ECLS and Impella 5.0 pump implantation was 9 [0-30] hours. Among these 41 patients, 25 died 6±6 days after implantation. They were older (53±12 vs. 43±12 years, P=0.01) with acute coronary syndrome as the primary etiology (64% vs. 13%, P=0.0007). In univariate analysis, patients who died exhibited a lower mean arterial pressure (74±17 vs. 89±9 mmHg, P=0.01), a higher level of troponin (24,000±38,000 vs. 3,500±5,000 mg/dL, P=0.048), a higher level of serum lactate (8.3±7.4 vs. 4.2±3.8 mmol/L, P=0.05) and more frequent cardiac arrest at admission (80% vs. 25%, P=0.03). In multivariate Cox regression analysis, a serum lactate level of >7.9 mmol/L (P=0.008) was found to be an independent predictor of mortality. Conclusions: In INTERMACS 1 patients who require urgent ECLS for restoring hemodynamics and organ perfusion, an upgrade from ECLS to ECMELLA is relevant if the serum lactate level is ≤7.9 mmol/L.

Hemolysis induced by Left Ventricular Assist Device is associated with proximal tubulopathy.

BACKGROUND: Chronic subclinical hemolysis is frequent in patients implanted with Left Ventricular Assist Device (LVAD) and is associated with adverse outcomes. Consequences of LVADs-induced subclinical hemolysis on kidney structure and function is currently unknown. METHODS: Thirty-three patients implanted with a Heartmate II LVAD (Abbott, Inc, Chicago IL) were retrospectively studied. Hemolysis, Acute Kidney Injury (AKI) and the evolution of estimated Glomerular Filtration Rate were analyzed. Proximal Tubulopathy (PT) groups were defined according to proteinuria, normoglycemic glycosuria, and electrolytic disorders. The Receiver Operating Characteristic (ROC) curve was used to analyze threshold of LDH values associated with PT. RESULTS: Median LDH between PT groups were statistically different, 688 IU/L [642-703] and 356 IU/L [320-494] in the "PT" and "no PT" groups, respectively p = 0.006. To determine PT group, LDH threshold > 600 IU/L was associated with a sensitivity of 85.7% (95% CI, 42.1-99.6) and a specificity of 84.6% (95% CI, 65.1-95.6). The ROC's Area Under Curve was 0.83 (95% CI, 0.68-0.98). In the "PT" group, patients had 4.2 [2.5-5.0] AKI episodes per year of exposure, versus 1.6 [0.4-3.7] in the "no PT" group, p = 0.03. A higher occurrence of AKI was associated with subsequent development of Chronic Kidney Disease (CKD) (p = 0.02) and death (p = 0.05). CONCLUSIONS: LVADs-induced subclinical hemolysis is associated with proximal tubular functional alterations, which in turn contribute to the occurrence of AKI and subsequent CKD. Owing to renal toxicity of hemolysis, measures to reduce subclinical hemolysis intensity as canula position or pump parameters should be systematically considered, as well as specific nephroprotective therapies.

A Survey of Cardiac Surgery Infections With PICO Negative Pressure Therapy in High-Risk Patients.

BACKGROUND: Surgical site complications represent major concerns in many surgical specialties and lead to an increased length of hospital stay and the need for additional treatments and care. This investigation aimed to report survey data from the introduction of the PICO negative pressure wound therapy system (Smith & Nephew, Hull, United Kingdom) in a single hospital in France regarding cardiac surgical procedures through standard median sternotomy. METHODS: The patients in this study were at high risk of developing surgical site infections. PICO was used immediately postoperatively on the closed incision sites in all patients undergoing cardiac surgical procedures. Data were compared with a retrospective cohort of patients in whom PICO had not been used postoperatively. In total, 233 anonymized patient records were reviewed, 142 of which used the PICO device and 91 of which did not. RESULTS: PICO was shown to provide both clinical and economic benefits over standard care across a range of different cardiac surgical patients. The rates of complications, including deep surgical wound infections and mediastinitis, were reduced. CONCLUSIONS: As noted, PICO had advantages over standard care in these patients, and complication rates decreased. This study demonstrated cost savings and an increase in available surgical and hospital capacity related to PICO use.

A difficult decision: what should we do when malignant tumours are diagnosed in patients supported by left ventricular assist devices?

OBJECTIVES: Left ventricular assist devices (LVADs) are used as a bridge to heart transplantation. During the preimplantation or pretransplantation screening, malignant tumours can be discovered. Owing to the lack of guidelines, the management is difficult. We describe our perioperative approach and the patients' outcomes. METHODS: Between 2006 and 2014, 55 patients underwent implantation of HeartMate II LVAD. Five were diagnosed with malignant tumours: 2 renal, 2 lung and 1 breast tumours. The renal tumours were diagnosed during the preimplantation screening. An LVAD was implanted in both followed by partial nephrectomies 8 and 9 months later. The lung cancers were diagnosed after device implantation, a left pulmonary segmentectomy and a right upper sleeve lobectomy were performed. The breast cancer was diagnosed few months after support and a tumourectomy with lymphadenectomy was performed. RESULTS: Tumour resection was performed successfully in all patients. Prior to surgery haemostasis, device and heart function were evaluated. During surgery, haemodynamics and anticoagulation were monitored. Reoperations were necessary to evacuate haemothorax after lobectomy and an abdominal haematoma post-nephrectomy. After discussion with oncologists, 3 patients were relisted for heart transplantation. Two were successfully transplanted 2 and 3 years after partial nephrectomy with an actual survival of 56 and 59 months after the cancer diagnosis. The follow-up revealed no cancer recurrences. CONCLUSIONS: Malignant tumours during support with LVAD can be successfully resected. A multidisciplinary evaluation in these high-risk patients is mandatory. After careful evaluation, regaining the patient's heart transplant candidacy is possible.

Is anti-platelet therapy needed in continuous flow left ventricular assist device patients? A single-centre experience.

OBJECTIVES: We report our 5-year experience of continuous flow left ventricular assist device (LVAD) implantation without the use of anti-platelet therapy. METHODS: Between February 2006 and September 2011, 27 patients (26 men; 1 woman) were implanted with a continuous flow LVAD (HeartMate II, Thoratec Corporation, Pleasanton, CA, USA). The mean age was 55.7 ± 9.9 years. The mean duration of support was 479 ± 436 (1-1555) days with 35.4 patient-years on support. Twenty-one patients were implanted as a bridge to transplantation and 6 for destination therapy. The anticoagulation regimen was fluindione for all patients, with aspirin for only 4 patients. At the beginning of our experience, aspirin was administered to 4 patients for 6, 15, 60 and 460 days. Due to gastrointestinal (GI) bleeding and epistaxis, aspirin was discontinued, and since August 2006, no patients have received anti-platelet therapy. RESULTS: At 3 years, the survival rate during support was 76%. The most common postoperative adverse event was GI bleeding (19%) and epistaxis (30%) (median time: 26 days) for patients receiving fluindione and aspirin. The mean International Normalized Ratio (INR) was 2.58 ± 0.74 during support. Fifteen patients have been tested for acquired Von Willebrand disease. A diminished ratio of collagen-binding capacity and ristocetin cofactor activity to Von Willebrand factor antigen was observed in 7 patients. In the postoperative period, 2 patients presented with ischaemic stroke at 1 and 8 months. One of these 2 patients had a previous history of carotid stenosis with ischaemic stroke. There were no patients with haemorrhagic stroke, transient ischaemic attack or pump thrombosis. The event rate of stroke (ischaemic and haemorrhagic) per patient-year was 0.059 among the patients without aspirin with fluindione regimen only. CONCLUSIONS: A fluindione regimen without aspirin in long-duration LVAD support appears to not increase thromboembolic events and could lead to a diminished risk of haemorrhagic stroke.

The Ross procedure in endocarditis: a report of 28 cases.

OBJECTIVES: The Ross procedure has received increasing interest as an attractive alternative to a prosthetic aortic valve. Given its presumably greater resistance to infection, the pulmonary autograft is theoretically preferable for active endocarditis. The objective of this retrospective study was to present our experience in aortic valve endocarditis treated using the Ross procedure. METHODS: Between May 1997 and February 2011, the Ross procedure was performed on 142 patients in our institution. Twenty-eight patients had aortic valve endocarditis at the time of operation. Fourteen patients had urgent or emergency procedures, and 13 had active disease at the time of surgery. Twelve patients were alcoholics and/or drug addicts. Eight patients had an abscess of the aortic annulus. Clinical follow-up was complete. RESULTS: Hospital mortality was 10.7%. Overall patient survival (± standard deviation) was 47 ± 13% at 10 years with no cardiac-related death during the mean follow-up of 6.4 ± 4.2 years. There were 3 cases of recurrent endocarditis including anterior mitral leaflets endocarditis and right-sided endocarditis to another germ in a drug addict. Four patients required further surgery, 2 on the pulmonary autograft; 18 of the 19 survivors were in New York Heart Association class I. At the final investigation, all patients had no or grade I autograft regurgitation. The mean pressure gradient across the homograft was 9 ± 7.5, 11 ± 9.5 and 15 ± 9.5 mmHg, respectively, for patients between 0-3, 4-9 and >9 years. CONCLUSIONS: Endocarditis can be treated with good results using the Ross procedure, with a very low rate of recurrence of endocarditis.

Favorable evolution of a 43-year-old Starr-Edwards valve in the tricuspid position.

The durability of a Starr-Edwards valve implanted in the tricuspid position in 1967 to treat Ebstein's disease with tricuspid valve regurgitation. At surgery, cardiac permanent pacing for postoperative complete atrioventricular block was achieved using a nuclear-powered pacemaker (NP). Although the 43rd year of cardiologic follow up was free from complications, the patient--a 74-year-old woman--suffered symptomatic mitral regurgitation and underwent a redo mitral valve replacement, during which the Starr-Edwards valve and NP were left in place.

Transapical aortic valve implantation in Rouen: four years' experience with the Edwards transcatheter prosthesis.

BACKGROUND: The first French transapical transcatheter aortic valve implantation (TAVI) was performed in July 2007 in our department. AIMS: To report 4-year outcomes of transapical implantation with the Edwards transcatheter bioprosthesis. METHODS: We prospectively evaluated consecutive patients who underwent transapical implantation with an Edwards transcatheter bioprosthesis between July 2007 and October 2011. Patients were not suitable for conventional surgery (due to severe comorbidities) or transfemoral implantation (due to poor femoral access). RESULTS: Among 61 patients (59.0% men), mean logistic EuroSCORE was 27.5 ± 14.9% and mean age was 81.0 ± 6.8 years. Successful valve implantation was achieved in 59/61 patients (96.7%) of patients. The other two patients required conversion to conventional surgery due to prosthesis embolization and died. Six additional patients died in the postoperative period. Causes of perioperative death were two septic shocks (one of peritonitis), two multi-organ failure, one ventricular fibrillation and one respiratory insufficiency. Intraprocedural stroke was not observed in any patient. The actuarial survival rates at 1, 2 and 4 years were 73.8%, 67.2% and 41.0%. During this 4-year period, four patients died of cardiovascular events, but no impairment of transprosthesis gradient was observed. CONCLUSION: Our series of 61 patients who underwent transapical implantation of the Edwards transcatheter bioprosthesis shows satisfactory results, similar to other reports, considering the high level of severity of patients referred for this method. Transapical access is a reliable alternative method for patients that cannot benefit from a transfemoral approach.

Coronary artery dissection after surgical cryoablation procedure.

Cryoablation can be used to treat atrial fibrillation (AF) surgically. We describe a 71-year-old woman who underwent cryoablation after 6 months of AF. Four hours post-surgery, electrocardiographic changes were observed in the circumflex artery territory associated with hemodynamic instability, which responded to inotropic agents. Angiography revealed a diffuse circumflex artery spasm with a heterogeneous aspect of the posterior branch evoking a dissection. Platelet anti-aggregant and trinitrine therapy were started. Recovery was uneventful and the patient was discharged on day 13. Cryoablation-associated circumflex artery dissection is rare. Caution is required when locating the ablation lines to avoid coronary artery injury.

Occurrence of an ascending aorta aneurysm 25 years after cure of a tetralogy of Fallot.

The patient, who had undergone a complete cure of a tetralogy of Fallot 25 years previously, was discovered to have an ascending aorta aneurysm on echography. Bentall's procedure was carried-out, using a modified indirect coronary artery transplantation based on the Cabrol technique. As reported in the literature complications are mainly right sided and less frequently occur on the left side in this disease. Including the hypothesis of the overload volume which may provoke aortic root dilation, there is also an intrinsic pathology of the media which could often be related to embryogenesis abnormalities, i.e., abnormal migration of cardiac neural crest cells which may explain this condition.

Prolonged cardiac dysfunction after withdrawal of chronic cocaine exposure in rats.

Cocaine abuse causes myocardial dysfunction and induces oxidative stress. However, the reversibility of these effects is unknown. We evaluated myocardial function and oxidative stress after cocaine withdrawal, in a rat model of chronic cocaine exposure. Standard echocardiography and Doppler tissue imaging were performed after 4 weeks (W4) of cocaine administration (2 x 7.5 mg/kg/d, i.p.) and 4 weeks after interruption (W8). At these time points, redox state (reduced glutathione GSH, oxidized glutathione GSH, and GSH/GSSG) as well as activities of GSH peroxidase (GPX), superoxide dismutase (SOD), and catalase were determined in the left ventricle (LV). At W4, LV fractional shortening, posterior wall thickening, systolic myocardial ventricular gradient (SMVG), dP/dt(max), and dp/dt(min) were decreased, compared with control values while LV myocardial thickness was increased. At W8, even though dP/dtmax and dp/dt(min) were restored, myocardial function was still impaired as demonstrated by the decrease in posterior wall thickening, and systolic myocardial velocity gradient. At W4, CAT and GPX activities as well as GSH/GSSG ratio were reduced while SOD activity was increased. Antioxidant markers and redox ratio remained altered 4 weeks after the last injection. Thus, these data demonstrate the persistence of LV dysfunction after cocaine withdrawal, which occurs in a context of a deficit in antioxidant defenses.