Endovascular therapy for intracranial infectious aneurysms associated with a left ventricular assist device: illustrative case.

BACKGROUND: Cerebrovascular events and infection are among the most common complications of left ventricular assist device (LVAD) therapy. The authors reported on a patient with an infectious intracranial aneurysm (IIA) associated with LVAD infection that was successfully occluded by endovascular therapy. OBSERVATIONS: A 37-year-old man with severe heart failure received an implantable LVAD. He was diagnosed with candidemia due to driveline infection 44 months after LVAD implantation, and empirical antibiotic therapy was started. After 4 days of antibiotic treatment, the patient experienced sudden dizziness. Computed tomography (CT) revealed subarachnoid hemorrhage in the right frontal lobe, and CT angiography revealed multiple aneurysms in the peripheral lesion of the anterior cerebral artery (ACA) and middle cerebral artery. Two weeks and 4 days after the first bleeding, aneurysms on the ACA reruptured. Each aneurysm was treated with endovascular embolization using n-butyl cyanoacrylate. Subsequently, the patient had no rebleeding of IIAs. The LVAD was replaced, and bloodstream infection was controlled. He received a heart transplant and was independent 2 years after the heart transplant. LESSONS: LVAD-associated IIAs have high mortality and an increased risk of surgical complications. However, endovascular obliteration may be safe and thus improve prognosis.

Potential of the EVAHEART 2 Double-Cuff Tipless Inflow Cannula for Prevention of Thromboembolic Events.

A 32-year-old man, who had developed fulminant myocarditis leading to asystole, underwent implantation of an EVAHEART 2 left ventricular assist system with a double-cuff tipless inflow cannula and a concurrent Fontan operation. Approximately 2 years after the simultaneous EVAHEART 2 implantation and the Fontan operation, the patient underwent heart transplantation. There was no device-related thromboembolism or pump malfunction under adequate antithrombotic management during the postoperative support period. Computed tomography showed no malposition of the inflow cannula irrespective of the left ventricular chamber size. Macroscopically, the left ventricular cavity of the excised heart revealed a smooth inflow ostium with appropriate intimal proliferation and without pannus or wedge thrombus formation. These findings suggest the utility of the double-cuff tipless inflow cannula for long-term clinical applications, which may lead to favorable outcomes during long-term patient management. The double-cuff tipless inflow cannula, which does not protrude into the left ventricular cavity, potentially contributes to the prevention of suction events and the collision of the inflow cannula with the interventricular septum and left ventricular free wall. Further investigation is required to confirm the role of the unique EVAHEART 2 inflow cannula in reducing thromboembolic events.

[Heart Transplantation for Older Patients].

The number of older donors is increasing in the limited number of donors in Japan. The number of older donors is increasing, and recipients are also ageing as the waiting period for transplantation becomes longer. The age of 60 years is one of the most important criteria for heart transplantation in Japan. Forty-two heart transplantations performed in our institution, and 12 cases were from donors aged over 60 years and seven recipients were older than 60 years at the time of transplantation. In four cases, both donor and recipient were over 60 years of age. All of these patients were discharged home after transplantation. As the number of older donors and recipients is expected to increase in the future, the number of marginal cases based on the status of not only the donor but also the recipient is expected to increase. The evaluation of coronary lesions and the identification of comorbid diseases, including malignant diseases, will become more important. A positive and careful overall decision at the time of transplantation is essential.

Fatal Pulmonary Hemorrhagic Infarction Caused by Pulmonary Vein Thrombotic Occlusion During Venoarterial Extracorporeal Membrane Oxygenation.

A 20-year-old man with arrhythmogenic right ventricular cardiomyopathy (ARVC) was resuscitated from ventricular fibrillation. He was transferred to our hospital because of progressive multiorgan dysfunction despite mechanical circulatory support with peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) and intra-aortic balloon pump (IABP). At admission to our hospital, chest X-ray showed bilateral complete lung opacification, and echocardiography revealed a massive thrombus occupying the left atrium (LA) and left ventricle (LV). Conversion to central ECMO with transapical LV venting and thrombectomy were performed. The huge LA thrombus occluded all pulmonary veins (PVs). Despite the surgery and intensive care, complete lung opacity remained, and he died of multiorgan failure associated with sepsis. Autopsy demonstrated bilateral pulmonary multiple red infarctions, and histopathology showed alveolar wall necrosis with extensive hemorrhage, confirming a diagnosis of pulmonary hemorrhagic infarction. Extensive pulmonary infarction was attributable to PV occlusion due to massive LA thrombus. PV thrombosis should be considered when refractory lung opacities are encountered during VA-ECMO and necessitates early intervention.

Investigating the cause of hemolysis in patients supported by a pulsatile ventricular assist device.

A survey conducted by Abiomed, Inc. revealed that 10 of 60 patients who received ventricular assistance via the AB5000 ventricular assist device (VAD) experienced hemolysis. The present study was conducted to investigate which factors influence hemolysis under pulsatile-flow VADs such as the AB5000. We compared the specificity of the AB5000 and its driving console with those of the NIPRO-VAD and VCT50χ under severe heart failure conditions using a mock circulatory system with a glycerol water solution. We used the mock circuit with bovine blood to confirm which pump conditions were most likely to cause hemolysis. In addition, we measured the shear velocity using particle image velocimetry by analyzing the seeding particle motion for both the AB5000 and NIPRO-VAD under the same conditions as those indicated in the initial experiment. Finally, we analyzed the correlation between negative pressure, exposure time, and hemolysis by continuously exposing fixed vacuum pressures for fixed times in a sealed device injected with bovine blood. Applying higher vacuum pressure to the AB5000 pump yielded a larger minimum inlet pressure and a longer exposure time when the negative pressure was under - 10 mmHg. The plasma-free hemoglobin increased as more negative pressure was driven into the AB5000 pump. Moreover, the negative pressure interacted with the exposure time, inducing hemolysis. This study revealed that negative pressure and exposure time were both associated with hemolysis.

Successful papillary muscle approximation for severe mitral regurgitation via apical cuff hole in HeartMate 3 implantation via left anterior thoracotomy.

We herein report a case of successful papillary muscle approximation for severe mitral regurgitation and HeartMate 3 left ventricular assist device implantation via left anterior thoracotomy in a 39-year-old man diagnosed with dilated cardiomyopathy. He underwent papillary muscle approximation in the mitral valve for severe functional regurgitation via the apical cuff hole. The postoperative course was uneventful. Echocardiography revealed that mitral regurgitation has disappeared. He was awaiting heart transplantation while working.

Aortic root morphology can cause early bioprosthetic valve failure of externally mounted pericardial bioprosthesis.

A 73-year-old woman with a narrow aortic root had undergone aortic valve replacement with a 19-mm Mitroflow valve. Aortic annular enlargement with Manouguian's technique was performed, and the bioprosthesis had been implanted on the tilt in a supra-annular position. Four years after the implantation, echocardiography showed a significant de novo aortic regurgitation, which had not been detected 1 year earlier. In the reoperation, the left coronary leaflet of the bioprosthesis had attached and fused to the wall of the sinus of Valsalva, causing deformation of the valve leaflet and a commissural gap between the left and right coronary leaflets, which appeared to have caused the de novo aortic regurgitation. We assessed the cause of early valve deterioration by focusing on the morphology of the aortic root. Preoperative understanding of the aortic root morphology would help to avoid early valve dysfunction for aortic valve replacement with an externally mounted bioprosthesis.

Long-term function of Hydrofit as hemostatic sealant: abridged republication.

The newly-designed hemostatic sealant, Hydrofit, was developed in Japan and consists of a urethane-based polymer without blood products. By applying Hydrofit gel to an anastomosis site on the aorta, water contact initiates a chemical change in the forming elastomer which adheres rapidly and tightly. We experienced an extirpation of Hydrofit gel that had been applied 4 years and 8 months previously in a 42-year-old female who underwent aortic valve replacement and graft replacement of the ascending aorta. The Hydrofit left around the aortic graft suture line was without infection and functioned very well as an elastic sealant for a long period.

A therapeutic concept to resolve a possible coronary desaturation under Ecpella support and maximize the potential for myocardial recovery: combination of veno-arteriovenous extracorporeal membrane oxygenation and Impella (VAVEcpella).

INTRODUCTION: Ecpella, a combination of veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO) and Impella, may result in the differential hypoxia in patients with cardiogenic shock and severe lung dysfunction. Here, we report a solution of this Ecpella-induced unfavorable phenomenon. CASE REPORT: A 70-year-old man developed cardiogenic shock from fulminant myocarditis. As we established Ecpella but immediately significant differential hypoxia became apparent, the ECMO configuration was switched from V-A to veno-arteriovenous (V-AV): a combination of V-AV ECMO and Impella, newly termed VAVEcpella, was instituted. The differential hypoxia resolved, and he was successfully weaned from mechanical circulatory support. DISCUSSION AND CONCLUSION: VAVEcpella is an effective configuration to resolve Ecpella-induced differential hypoxia and may contribute to restoration of normal cardiac function.

Efficacy of preoperative electrocardiographic-gated computed tomography in predicting the accurate aortic annulus diameter in surgical aortic valve replacement.

OBJECTIVE: Electrocardiographic (ECG)-gated computed tomography (CT) can be used to determine which valve and size should be used in transcatheter aortic valve replacement (TAVR). It is beneficial to predict the accurate annulus diameter in surgical aortic valve replacement (SAVR), which can help in determining the surgical strategy. We aimed to compare the predicted aortic annulus size with the actual annulus size measured intraoperatively and to examine its validity. METHODS: A total of 88 patients underwent isolated or concomitant SAVR in 2018 at our hospital. The study population consisted of 45 patients who underwent preoperative CT assessment and intraoperative measurement. The perimeter- and area-derived diameters at the level of basal attachments were determined using CT, and the lower value among the two was defined as the predicted aortic annulus (CTpredict). The predicted aortic annulus (TTEpredict) was measured by transthoracic echography in the parasternal long-axis view. An actual-sized ball sizer was inserted into the annulus intraoperatively. True annulus size was determined as the labeled size that just fits on the annulus, and labeled size plus 1 mm was determined as one that passes through the annulus. RESULTS: There was better agreement with minimal bias between CTpredict and true annulus size as demonstrated in the Bland-Altman analysis with an intraclass correlation coefficient of 0.796 compared with TTEpredict. CONCLUSION: ECG-gated CT is also helpful in predicting the annulus diameter even in patients undergoing SAVR. This has important clinical implications for planning SAVR, including the surgical approach.

Chronologic Changes in Residual False Lumen Under Continuous-Flow Circulation.

We experienced a rare case of intraoperative type A aortic dissection during HeartMate II (Abbott, Chicago, IL) implantation and subsequently performed emergent total aortic arch replacement. Periodic follow-up computed tomography confirmed that the residual false lumen after the aortic repair had gradually thrombosed over time regardless of sufficient antithrombotic therapy. We analyzed the chronologic changes in the false lumen morphology, showing transient enlargement of the aortic diameter 1 year postoperatively and then a reduction at 3 years postoperatively. We report on the fate of residual false lumen after aortic repair under continuous-flow left ventricular assist device circulation.

A staged surgical strategy for cardiogenic shock and iatrogenic ventricular septal perforation due to a malpositioned catheter.

A 59-year-old woman fell into cardiogenic shock due to acute myocardial infarction with total occlusion of the left anterior descending artery. Although intra-aortic balloon pump was inserted and a coronary stent was placed, she went into cardiopulmonary arrest and percutaneous veno-arterial extracorporeal membrane oxygenation (ECMO) was initiated. She was transferred to our hospital after drainage for pericardial effusion. Computed tomography revealed the drainage catheter lying through the right ventricular free wall and the ventricular septum, and leading into the left ventricle. She showed multiple organ failure and disseminated intravascular coagulation syndrome due to insufficient ECMO flow. Conversion to central ECMO after catheter removal was performed and her general condition improved; however, ventricular septal shunt remained. Repair of the perforation and ECMO removal was performed 15 days after the first operation. The combination of optimal mechanical circulatory support and the staged surgical repair contributed to her dramatic recovery.

Determinants of Changes in Arterial Stiffness after Thoracic Endovascular Aortic Repair.

BACKGROUND: Aortic stent grafting can cause aortic stiffening and increase pulse wave velocity (PWV), which can potentially affect long-term cardiovascular outcomes. The aim of this study was to clarify the factors contributing to increases in PWV after thoracic endovascular aortic repair (TEVAR). METHODS: We included 64 patients with thoracic aortic pathology (51 men; mean age, 73 years) who underwent elective TEVAR, in this study. TEVAR was performed for degenerative aortic aneurysm (n = 43) or aortic dissection (n = 21), and the treatment length was 175 ± 52 mm. Brachial-ankle PWV (baPWV) was obtained before and 1 week after TEVAR. Univariable and multivariable logistic regression analyses were used to determine the predictors of increases in baPWV of ≥100 cm/sec after TEVAR. RESULTS: baPWV increased from 1,851 ± 392 cm/sec to 2,047 ± 479 cm/sec, and the change in baPWV (ΔbaPWV) was 195 ± 339 cm/sec (95% confidence interval, 111-280). Thirty-seven patients (58%) had ΔbaPWV ≥100 cm/sec after TEVAR. In the multivariable analysis, in addition to Δheart rate and Δsystolic blood pressure, age (odds ratio, 1.21/year; 95% confidence interval, 1.05-1.40) and coronary artery disease (odds ratio, 12.0; 95% confidence interval, 1.20-121) were independent determinants of ΔbaPWV ≥100 cm/sec after TEVAR, whereas ΔbaPWV ≥100 cm/sec was not associated with treatment length or device type. CONCLUSIONS: TEVAR was associated with PWV progression, especially in older patients with coronary artery disease, whereas treatment length or device type was not a predictor of PWV progression after TEVAR.

Preoperative distal aortic diameter is a significant predictor of late aorta-related events after endovascular repair for chronic type B aortic dissection.

OBJECTIVES: Long-term therapeutic effects of thoracic endovascular aortic repair (TEVAR) for chronic type B aortic dissection remain controversial. This study aimed to evaluate the possible predictors of late aortic rupture and re-interventions after TEVAR. METHODS: We retrospectively reviewed the operative outcomes of 40 patients who underwent TEVAR for chronic type B aortic dissection at Kyushu University Hospital. During a mean follow-up period of 39.2 months, we assessed aortic morphology via computed tomography and then employed a multivariable Cox regression analysis in an attempt to identify the predictors of late aorta-related events. RESULTS: The early success rate of TEVAR was 100%. During the follow-up, however, three patients died from aortic rupture. Eight patients required aortic re-intervention, including thoraco-abdominal aortic graft replacement, repeated TEVAR, total arch replacement and EVAR. Multivariable Cox regression analysis revealed that the preoperative maximum distal aortic diameter was a significant predictor of late aorta-related events. The cutoff value of the distal aortic diameter was 40 mm. Freedom from aorta-related events was 94.6% at 1 year and 78.3% at 3 years. The survival rate was not significantly different despite the re-intervention. CONCLUSIONS: TEVAR is an effective treatment for chronic type B dissection, with acceptable mid-term results. The preoperative distal aortic diameter is a significant risk factor for late aorta-related events. When the maximum distal aortic diameter is ≥ 40 mm, a therapeutic strategy should be developed taking into consideration the possible need for aortic re-intervention.

Pneumopericardium suggesting left ventricular assist device-related gastrointestinal complication.

We report an uncommon case of ventricular assist device-related infection and resultant fistula formation into the gastrointestinal tract. A 69-year-old man, who had undergone implantation of a HeartMate II 1 year earlier secondary to ischemic cardiomyopathy, presented to our hospital with a high fever. Computed tomography showed unusual gas collection around the heart apex (i.e., pneumopericardium), which had not been detected before. The patient developed sudden melena with fresh blood without abdominal symptoms 1 month after beginning antibiotic therapy. Emergent colonoscopy showed that the HeartMate II strain relief of the inflow conduit had penetrated the transverse colon. We immediately performed laparoscopy-assisted left-sided hemicolectomy and found intraoperatively that a fistula had formed between the splenic flexure and the pericardial cavity. Subsequently, the HeartMate II system was totally explanted and replaced with an Impella 5.0 for alternative hemodynamic support. In our patient, pneumopericardium might have been an early sign of a hidden gastrointestinal complication. Our experience is a caution for clinicians who manage patients with ventricular assist device support via the apex.

Successful off-pump surgical release for extrinsic compression of outflow graft obstruction of a left ventricular assist device.

A 36-year-old woman had received support with the Jarvik 2000 left ventricular assist device for 3 years. Cardiac computed tomography revealed outflow graft obstruction, which appeared as external compression of the outflow graft. The patient underwent surgical release of the obstruction after resternotomy. Yellow sediment had become encrusted in the enclosed space between the covering graft and outflow graft and appeared to have been derived from plasma contents. Successful release of the obstruction was achieved by cutting open the covering graft without cardiopulmonary bypass. Neither pump exchange nor outflow graft exchange was required. This off-pump surgery can be a beneficial procedure in terms of less invasiveness and good curability.

Jarvik 2000 axial flow ventricular assist device in right single ventricle after Fontan operation.

We present a case of successful ventricular assist device support in a 13-year-old female diagnosed with right single ventricle, asplenia, dextrocardia, who had undergone a Fontan operation at 4 years old in an associated children hospital. She underwent placement of Jarvik 2000 axial flow ventricular assist device to the morphologic right ventricle which worked as systemic ventricle. The postoperative course was not eventful. She was waiting for heart transplantation attending high school 3 years after implantation.

Single-stage hybrid total arch replacement for extended arch aneurysms.

OBJECTIVE: The therapeutic strategy for extended aortic arch aneurysms remains controversial and has changed substantially since thoracic endovascular aortic repair was introduced. We applied single-stage hybrid (s-hybrid) total arch replacement (TAR), which involved ascending aorta replacement and debranching of arch vessels, consecutively performed with thoracic endovascular aortic repair for extended arch aneurysms. The aim of this study was to investigate the short-term results of s-hybrid TAR and to clarify the benefit of this method. METHODS: We reviewed the operative results of 62 patients who underwent elective s-hybrid TAR or conventional TAR (c-TAR) through the median approach from 2008 to 2017. We used the s-hybrid approach in 15 patients and the c-TAR approach in 47 patients. In both groups, axillary arterial perfusion and selective antegrade cerebral perfusion under moderate hypothermia were applied for brain protection. We compared the perioperative outcomes of the two groups. RESULTS: We completed s-hybrid TAR in all 15 patients with extended aneurysms. The s-hybrid group required shorter times for myocardial ischemia, selective antegrade cerebral perfusion, and circulatory arrest of the lower body compared with the c-TAR group. The patients with complicated recurrent laryngeal nerve palsy and long ventilation support times were fewer in the s-hybrid group. No patient had substantial endoleaks or permanent paraplegia. The in-hospital mortality rates were 6.7% in the s-hybrid group and 0% in the c-TAR group. CONCLUSIONS: The s-hybrid TAR has the same or better perioperative outcomes compared with the c-TAR approach. For extended aneurysms, this technique could resolve the problem of respiratory failure induced by left thoracotomy and also resolve the problem of rupture during the waiting period in staged surgery.