Bridging Over Troubled Waters-How the United States 2018 Heart Allocation System Altered Transplant Bridging Strategies.

As we approach the five-year anniversary of the 2018 heart allocation system in the United States, it is imperative to consider the changing landscape of mechanical circulatory support and the strategies used to bridge patients into heart transplants. This manuscript reviews the history of the heart allocation system, as well as the conditions that led to its multiple revisions. We discuss initial outcomes following the implementation of the new allocation system, including the impact on waitlist mortality and post-transplant outcomes. We also give special consideration to changes in bridging strategies using venoarterial extracorporeal membrane oxygenation (VA ECMO), intra-aortic balloon pumps, and durable left ventricular assist devices (LVADs).

Cardiac allograft vasculopathy in heart transplant recipients from hepatitis C viremic donors.

BACKGROUND: Recent studies suggest the transplantation of Hepatitis C (HCV) hearts from viremic donors is associated with comparable 1 year survival to nonviremic donors. Though HCV viremia is a known risk factor for accelerated atherosclerosis, data on cardiac allograft vasculopathy (CAV) outcomes are limited. We compared the incidence of CAV in heart transplant recipients from HCV viremic donors (nucleic acid amplification test positive; NAT+) compared to non-HCV infected donors (NAT-). METHODS: We retrospectively reviewed annual coronary angiograms with intravascular ultrasound from April 2017 to August 2020 at two large cardiac transplant centers. CAV was graded according to ISHLT guidelines. Maximal intimal thickness (MIT) ≥ 0.5 mm was considered significant for subclinical disease. RESULTS: Among 270 heart transplant recipients (mean age 54; 77% male), 62 patients were transplanted from NAT+ donors. CAV ≥ grade 1 was present in 8.8% of the NAT+ versus 16.8% of the NAT- group at 1 year, 20% versus 28.8% at 2 years, and 33.3% versus 41.5% at 3 years. After adjusting for donor age, donor smoking history, recipient BMI, recipient, hypertension, and recipient diabetes, NAT+ status did not confer increased risk of CAV (HR.80; 95% CI.45-1.40, p = 0.43) or subclinical IVUS disease (HR.87; 95% CI.58-1.30, p = 0.49). Additionally, there was no difference in the presence of rapidly progressive lesions on IVUS. CONCLUSION: Our data show that NAT+ donors conferred no increased risk for early CAV or subclinical IVUS disease following transplantation in a cohort of heart transplant patients who were treated for HCV, suggesting the short-term safety of this strategy to maximize the pool of available donor hearts.

Single center utilization and post-transplant outcomes of thoracoabdominal normothermic regional perfusion deceased cardiac donor organs.

INTRODUCTION: Thoracoabdominal normothermic regional perfusion (TA-NRP) following cardiac death is an emerging multivisceral organ procurement technique. Recent national studies on outcomes of presumptive TA-NRP-procured organs are limited by potential misclassification since TA-NRP is not differentiated from donation after cardiac death (DCD) in registry data. METHODS: We studied 22 donors whose designees consented to TA-NRP and organ procurement performed at our institution between January 20, 2020 and July 3, 2022. We identified these donors in SRTR to describe organ utilization and recipient outcomes and compared them to recipients of traditional DCD (tDCD) and donation after brain death (DBD) organs during the same timeframe. RESULTS: All 22 donors progressed to cardiac arrest and underwent TA-NRP followed by heart, lung, kidney, and/or liver procurement. Median donor age was 41 years, 55% had anoxic brain injury, 45% were hypertensive, 0% were diabetic, and median kidney donor profile index was 40%. TA-NRP utilization was high across all organ types (88%-100%), with a higher percentage of kidneys procured via TA-NRP compared to tDCD (88% vs. 72%, p = .02). Recipient and graft survival ranged from 89% to 100% and were comparable to tDCD and DBD recipients (p ≥ .2). Delayed graft function was lower for kidneys procured from TA-NRP compared to tDCD donors (27% vs. 44%, p = .045). CONCLUSION: Procurement from TA-NRP donors yielded high organ utilization, with outcomes comparable to tDCD and DBD recipients across organ types. Further large-scale study of TA-NRP donors, facilitated by its capture in the national registry, will be critical to fully understand its impact as an organ procurement technique.

Prior infrarenal aortic surgery is not associated with increased risk of spinal cord ischemia after thoracic endovascular aortic repair and complex endovascular aortic repair.

OBJECTIVE: Patients with prior infrarenal aortic intervention represent an increasing demographic of patients undergoing thoracic endovascular aortic repair (TEVAR) and/or complex EVAR. Studies have suggested that prior abdominal aortic surgery is a risk factor for spinal cord ischemia (SCI). However, these results were largely based on single-center experiences with limited multi-institutional and national data that had assessed the clinical outcomes for these patients. The objective of the present study was to evaluate the effect of prior infrarenal aortic surgery on the occurrence of SCI. METHODS: The Society for Vascular Surgery Vascular Quality Initiative database was retrospectively reviewed to identify all patients aged ≥18 years who had undergone TEVAR and/or complex EVAR from January 2012 to June 2020. Patients with previous thoracic or suprarenal aortic repair were excluded. The baseline and procedural characteristics and postoperative outcomes were compared between TEVAR and/or complex EVAR with and without previous infrarenal aortic repair. The primary outcome was postoperative SCI. The secondary outcomes included postoperative hospital length of stay, bowel ischemia, renal ischemia, and 30-day mortality. Multivariate regression was used to determine the independent predictors of postoperative SCI. Additional analysis was performed of the patients who had undergone isolated TEVAR. RESULTS: A total of 9506 patients met the inclusion criteria: 8691 (91.4%) had not undergone prior infrarenal aortic repair and 815 (8.6%) had undergone previous infrarenal aortic repair. Patients with previous infrarenal repair were older with an increased prevalence of chronic kidney disease (P = .001) and cardiovascular risk factors, including hypertension, chronic obstructive pulmonary disease, and positive smoking history (P < .001). These patients also presented with a larger maximal aortic diameter (6.06 ± 1.47 cm vs 5.15 ± 1.76 cm; P < .001) and required more stent-grafts (P < .001) with increased intraoperative blood transfusion requirements (P < .001), and longer procedure times (P < .001). Univariate analysis demonstrated no differences in postoperative SCI, postoperative hospital length of stay, bowel ischemia, or renal ischemia between the two groups. The 30-day mortality was significantly higher in patients with prior infrarenal repair (P = .001). On multivariate regression, prior infrarenal aortic repair was not a predictor of postoperative SCI. In contrast, aortic dissection (odds ratio [OR], 1.65; 95% confidence interval [CI], 1.26-2.16; P < .001), number of stent-grafts deployed (OR, 1.45; 95% CI, 1.30-1.62; P < .001), and units of packed red blood cells transfused intraoperatively (OR, 1.33; 95% CI, 1.03-1.73; P = .032) were independent predictors of postoperative SCI. CONCLUSIONS: Although the patients in the TEVAR and/or complex EVAR group with prior infrarenal aortic repair constituted a sicker cohort with higher 30-day mortality, the rate of SCI was comparable to that of the patients without prior repair. Previous infrarenal repair was not associated with the risk of SCI.

Clinical Use of Cangrelor After Percutaneous Coronary Intervention in Patients Requiring Mechanical Circulatory Support.

BACKGROUND: Patients with cardiogenic shock after percutaneous coronary intervention (PCI) may require mechanical circulatory support (MCS). The combination of dual antiplatelet therapy with cangrelor and continuous anticoagulation required for MCS may increase the risk of bleeding. OBJECTIVE: The objective of the study is to describe the complications and outcomes of patients who received cangrelor during MCS following PCI. METHODS: This is a single-center, retrospective, observational case series of 17 patients who received cangrelor while on MCS from June 2017 to September 2019. RESULTS: In a case series of 17 patients, 8 patients (47%) were supported with an Impella device and 4 patients (24%) with venoarterial (VA) extracorporeal membrane oxygenation (ECMO); 5 required (29%) concomitant VA ECMO and Impella support in the setting of cardiogenic shock. All patients received triple antithrombotic therapy with aspirin, heparin, and cangrelor. Cangrelor was commonly initiated at a median dose of 0.75 (range 0.5-4) µg/kg/min. Cangrelor dose adjustments included changes in increments up to 0.25 µg/kg/min with review of P2Y12 levels. A total of 10 patients (59%) experienced a bleeding event, most commonly located at the peripheral cannulation site (40%) and in the gastrointestinal tract (30%). Seven (70%) and 3 (30%) of the bleeding complications were classified as major and minor, respectively. No patient developed in-stent thrombosis during the hospitalization; 14 (82%) patients survived their MCS course. CONCLUSION AND RELEVANCE: This case series suggests that cangrelor doses less than 0.75 µg/kg/min may be beneficial. Larger studies should evaluate alternative dosing regimens.

Pulmonary Embolism Response Team activation during the COVID-19 pandemic in a New York City Academic Hospital: a retrospective cohort analysis.

Coronavirus disease 2019 (COVID-19) is associated with increased rates of deep vein thrombosis (DVT) and pulmonary embolism (PE). Pulmonary Embolism Response Teams (PERT) have previously been associated with improved outcomes. We aimed to investigate whether PERT utilization, recommendations, and outcomes for patients diagnosed with acute PE changed during the COVID-19 pandemic. This is a retrospective cohort study of all adult patients with acute PE who received care at an academic hospital system in New York City between March 1st and April 30th, 2020. These patients were compared against historic controls between March 1st and April 30th, 2019. PE severity, PERT utilization, initial management, PERT recommendations, and outcomes were compared. There were more cases of PE during the pandemic (82 vs. 59), but less PERT activations (26.8% vs. 64.4%, p < 0.001) despite similar markers of PE severity. PERT recommendations were similar before and during the pandemic; anticoagulation was most recommended (89.5% vs. 86.4%, p = 0.70). During the pandemic, those with PERT activations were more likely to be female (63.6% vs. 31.7%, p = 0.01), have a history of DVT/PE (22.7% vs. 1.7%, p = 0.01), and to be SARS-CoV-2 PCR negative (68.2% vs. 38.3% p = 0.02). PERT activation during the pandemic is associated with decreased length of stay (7.7 ± 7.7 vs. 13.2 ± 12.7 days, p = 0.02). PERT utilization decreased during the COVID-19 pandemic and its activation was associated with different biases. PERT recommendations and outcomes were similar before and during the pandemic, and led to decreased length of stay during the pandemic.

Surgical management of a pulsatile chest wall mass secondary to an ascending aortic aneurysm in a patient with bovine arch.

Ascending aortic pseudoaneurysms are rare, but life-threatening conditions, that often require intervention. While endovascular techniques have advanced significantly, the majority of these clinical scenarios preclude endovascular options and the primary treatment modality remains open surgical repair. Repair of an aortic pseudoaneurysm eroding through the sternum resulting in a pulsatile chest wall mass is technically challenging. We report the successful repair of a large ascending aortic pseudoaneurysm in a 62-year-old male with bovine arch anatomy and prior Type A dissection repair, presenting with contained rupture and a pulsatile chest wall mass.

Hemoadsorption for management of patients on veno-venous ECMO support for severe COVID-19 acute respiratory distress syndrome.

BACKGROUND AND AIM: Patients with severe coronavirus disease 2019 (COVID-19) develop a profound cytokine-mediated pro-inflammatory response. This study reports outcomes in 10 patients with COVID-19 supported on veno-venous extracorporeal membrane oxygenation (VV-ECMO) who were selected for the emergency use of a hemoadsorption column integrated in the ECMO circuit. MATERIALS AND METHODS: Pre and posttreatment, clinical data, and inflammatory markers were assessed to determine the safety and feasibility of using this system and to evaluate the clinical effect. RESULTS: During hemoadsorption, median levels of interleukin (IL)-2R, IL-6, and IL-10 decreased by 54%, 86%, and 64%, respectively. Reductions in other markers were observed for lactate dehydrogenase (-49%), ferritin (-46%), d-dimer (-7%), C-reactive protein (-55%), procalcitonin (-76%), and lactate (-44%). Vasoactive-inotrope scores decreased significantly over the treatment interval (-80%). The median hospital length of stay was 53 days (36-85) and at 90-days post cannulation, survival was 90% which was similar to a group of patients without the use of hemoadsorption. CONCLUSIONS: Addition of hemoadsorption to VV-ECMO in patients with severe COVID-19 is feasible and reduces measured cytokine levels. However, in this small series, the precise impact on the overall clinical course and survival benefit still remains unknown.

Perceptions of Training Pathways from Recent Cardiothoracic Surgery Graduates.

BACKGROUND: There are three cardiothoracic surgery (CTS) training pathways-general surgery residency followed by a CTS residency of 2-3 years (traditional), 4 years of general surgery and 3 years of CTS residency (4+3), and an integrated 6-year pathway (I-6). The goal of this study was to survey early career cardiothoracic surgeons regarding their training experiences. METHODS: An email-based survey was sent to cardiothoracic surgeons, who graduated between 2012-2017. Data on training pathway specific variables and overall satisfaction were collected. The primary endpoints were career preparation and satisfaction, scored on a scale from 1-100, 100 being the most positive. RESULTS: Four hundred seventy-seven emails were sent, with a response rate of 95/477 (20%). Seventy-six of the respondents (80%) were male; the mean age was 39. Seventy-seven (81.0%) completed a traditional training pathway, 7 (7.4%) completed a 4+3 pathway, and 11 (11.6%) completed an I-6 pathway. Participants felt prepared for practice with a mean response of 79.8 (range 31-100); mean career satisfaction was 87.6.  When asked which pathway respondents would choose in the current era, 52 (54.7%) would choose a traditional pathway, 17 (17.9%) a 4+3 pathway, and 19 (20.0%) an I-6 program; 7 (7.4%) did not respond. Twenty of 72 (27.8%) traditional pathway trained and 18/18(100%) integrated pathway trained surgeons would choose an integrated pathway. CONCLUSIONS: This is the first survey addressing perceptions of training from early-career cardiothoracic surgeons across all training pathways. Data from this study provides insights to better understand how to improve CTS training for the next generation of surgeons.

Management and tolerability of glecaprevir-pibrentasvir pharmacotherapy in hepatitis C viremic heart and lung transplant recipients.

We conducted a retrospective review of thoracic transplant recipients (22 heart and 16 lung transplant recipients) prospectively enrolled in a single-center observational study of HCV NAT+ organ transplantation in HCV NAT- recipients. All recipients were treated with 8 weeks of glecaprevir-pibrentasvir (GP) for HCV viremia in addition to standard triple immunosuppression post-transplant. Thoracic transplant recipients of HCV NAT- organs were used as a control (24 heart and 22 lung transplant recipients). Our primary outcome was to assess the effect of GP on tacrolimus dose requirements. Secondary objectives included assessing drug interactions with common post-transplant medications, adverse effects, and the need to hold or discontinue GP therapy. The median tacrolimus concentration-to-dose ratio (CDR) in the cohort was 184 (99-260) during GP therapy and 154 (78-304) over the first month after GP (P = .79). Trends in median tacrolimus CDR were similar on a per-week basis and per-patient basis. In three instances, concomitant posaconazole and GP led to hyperbilirubinemia and interruption of posaconazole. GP therapy was held in one heart transplant recipient and discontinued in another due to unresolving hyperbilirubinemia. Utilization of GP to treat HCV viremia post-thoracic transplant is feasible and safe, but requires modifications to post-transplant pharmacotherapy and careful monitoring for adverse effects.

Low left ventricular outflow tract velocity time integral is associated with poor outcomes in acute pulmonary embolism.

The left ventricular outflow tract (LVOT) velocity time integral (VTI) is an easily measured echocardiographic stroke volume index analog. Low values predict adverse outcomes in left ventricular failure. We postulate the left ventricular VTI may be a signal of right ventricular dysfunction in acute pulmonary embolism, and therefore a predictor of poor outcomes. We retrospectively reviewed echocardiograms on all Pulmonary Embolism Response Team activations at our institution at the time of pulmonary embolism diagnosis. Low LVOT VTI was defined as ⩽ 15 cm. We examined two composite outcomes: (1) in-hospital death or cardiac arrest; and (2) shock or need for primary reperfusion therapies. Sixty-one of 188 patients (32%) had a LVOT VTI of ⩽ 15 cm. Low VTI was associated with in-hospital death or cardiac arrest (odds ratio (OR) 6, 95% CI 2, 17.9; p = 0.0014) and shock or need for reperfusion (OR 23.3, 95% CI 6.6, 82.1; p < 0.0001). In a multivariable model, LVOT VTI ⩽ 15 remained significant for death or cardiac arrest (OR 3.48, 95% CI 1.02, 11.9; p = 0.047) and for shock or need for reperfusion (OR 8.12, 95% CI 1.62, 40.66; p = 0.011). Among intermediate-high-risk patients, low VTI was the only variable associated with the composite outcome of death, cardiac arrest, shock, or need for reperfusion (OR 14, 95% CI 1.7, 118.4; p = 0.015). LVOT VTI is associated with adverse short-term outcomes in acute pulmonary embolism. The VTI may help risk stratify patients with intermediate-high-risk pulmonary embolism.

Sedation Requirements in Patients on Venovenous or Venoarterial Extracorporeal Membrane Oxygenation.

Background:There is a paucity of data evaluating optimal dosing strategies of commonly utilized opioids and sedatives for patients on extracorporeal membrane oxygenation (ECMO) support where pharmacokinetic and pharmacodynamic variables of these administered agents are altered. Objective: To assess the daily dosing requirement of sedatives and analgesics for patients on venovenous (VV) and venoarterial (VA) ECMO after the initial ECMO cannulation period. Methods: We performed a retrospective, observational study of adult patients receiving sedation and analgesia while receiving ECMO support for at least 24 hours. Patients cannulated at an outside hospital more than 24 hours before transfer, those with a history of intravenous drug use or acute alcohol withdrawal, or those who died within 48 hours of ECMO initiation were excluded. Results: We evaluated 26 patients on ECMO, including 13 on VV and 13 on VA ECMO. The median dose of fentanyl was 140 µg/h, with the VV group requiring a higher dose compared with the VA group (167 vs 106 µg/h, P < 0.001). The median doses of dexmedetomidine and propofol were 0.7 µg/kg/h and 26 µg/kg/min, respectively, with no significant differences between groups (P = 0.38 and P = 0.24, respectively). The median daily doses of fentanyl, dexmedetomidine, and propofol did not significantly increase throughout the time on ECMO support. Conclusions and Relevance: We found that the overall opioid daily dosing requirements were lower than previously reported in the literature. Additionally, light sedation strategies with a target RASS of -1 to 0 are feasible in this patient population.

Early Detection, Prevention, and Management of Acute Limb Ischemia in Adults Supported With Venoarterial Extracorporeal Membrane Oxygenation.

Acute limb ischemia caused by peripheral venoarterial extracorporeal membrane oxygenation (ECMO) cannulation is associated with increased mortality. Early detection of limb hypoperfusion may lead to timely intervention and prevent irreversible muscle damage. Methods to determine the adequacy of tissue oxygenation in cannulated extremities include bedside physical examination, trending serum biochemical markers, and somatic near-infrared spectroscopy. To prevent ECMO-related limb ischemia events, interventions include the addition of distal antegrade perfusion catheters to the arterial ECMO canula, minimizing arterial cannula diameter, placing arterial and venous cannulae on opposite extremities, and adding a side-arm graft to the cannulated artery. If the limb develops early signs of ischemia, preventative measures such as distal perfusion catheter insertion or changing the location of the arterial cannula should be performed. Acute compartment syndrome requires emergency fasciotomy or amputation if the limb is unsalvageable. Opportunities for future research include improving monitoring technology and standardizing the use of the distal perfusion catheter.

Comparison of device-specific adverse event profiles between Impella platforms.

BACKGROUND: The Impella (Abiomed) ventricular support system is a family of temporary mechanical circulatory support (MCS) devices used to treat patients with cardiogenic shock, acute cardiogenic decompensation, and for high-risk percutaneous or surgical revascularization. These devices include the percutaneously implanted 2.5/cardiac power (CP) and the surgically implanted 5.0/left direct (LD). Despite the beneficial effects and increased usage of these devices, data to assess adverse outcomes and guide clinician decision-making between the Impella CP and 5.0/LD are limited. METHODS: This is a retrospective analysis of 91 consecutive patients who required at least 24 h of Impella support, from January 1, 2015 to December 31, 2019. Groups were stratified based on either initial Impella CP or 5.0/LD placement. Clinical outcomes and in-hospital complications were compared. RESULTS: Impella CP was implanted in 66 patients (mean age: 61 ± 15 years, male 71.2%) and Impella 5.0/LD was implanted in 25 patients (mean age: 62 ± 9 years, male 84.0%). There was greater stability of device position (p = .033), less incidence of hemolysis (p < .001), and less frequent need for additional MCS (p = .001) in patients implanted with the Impella 5.0/LD compared with Impella CP in this study cohort. Patients with Impella 5.0/LD were more likely to survive from Impella and survive to discharge. CONCLUSIONS: This study suggests that for patients who require temporary MCS for more than 24 h, the Impella 5.0/LD may have a more favorable device-specific adverse profile compared with the Impella CP.

Beyond stigma: Understanding the "inclined abstainers" in military behavioral health-care utilization.

Low treatment utilization in Soldiers with combat-related Posttraumatic Stress Disorder (PTSD) is an ongoing issue. The critical concern is to better understand factors which prohibit a Soldier with PTSD who wants help from seeking treatment (an "inclined abstainer"). A total of 537 Active Duty Soldiers on a US Army post completed a brief survey comprising psychometrically validated measures of stigma, behavioral health treatment beliefs, resilience, PTSD symptoms, and treatment intentions. Health-care records were prospectively tracked for 12 months to determine the relation between survey answers and treatment utilization. Sixty-three percent of those who acknowledged having a mental health-related problem did not seek help within a one-year period. Greater severity of PTSD symptoms was associated with an increased likelihood of behavioral health engagement. Soldiers that were classified as "inclined abstainers" were also more likely to endorse negative beliefs about psychotherapy and report higher levels of resilience as compared to "inclined actors." These results suggest that a treatment model of PTSD emphasizing self-efficacy and self-reliance, while addressing negative beliefs about psychotherapy, may help promote engagement of behavioral health services among Active Duty Soldiers.

Early airway dehiscence: Risk factors and outcomes with the rising incidence of extracorporeal membrane oxygenation as a bridge to lung transplantation.

BACKGROUND: Anastomotic complications occur in 7% to 18% of lung transplant recipients, among which airway dehiscence (AD) is particularly catastrophic. Using multi-institutional registry data, this study compared preoperative recipient/donor risk factors and outcomes in patients with and without AD and analyzed the effect of extracorporeal membrane oxygenation (ECMO) on the incidence of AD. METHODS: Data on adult lung transplants from 2007 to 2017 were provided by the Scientific Registry of Transplant Recipients. Patients receiving isolated lobar transplantation and patients with unknown AD status were excluded. Multivariable logistic regression identified independent risk factors for AD. Kaplan-Meier curves and log-rank tests describe mortality and graft survival. RESULTS: Of 18 122 lung transplants, 275 (1.5%) experienced AD. While the incidence of ECMO steadily increased from 0.7% to 5.9% over the study period, the incidence of AD remained relatively constant. Multivariable analysis revealed recipient male gender and prolonged ( > 48 hours) posttransplant mechanical ventilation as independent predictive factors for AD, while advanced donor age and single left lung transplant were protective factors. Recipient chronic steroid use, recipient diabetes, donor diabetes, and donor smoking history were not predictive of AD. Mortality and graft failure were significantly worse in the AD group. CONCLUSIONS: Despite increased ECMO utilization, the incidence of AD has remained stable. Multiple independent risk factors for AD were identified and poor postoperative outcomes confirmed. However, many known impediments to wound healing such as recipient chronic steroid use, recipient and donor diabetes, and donor smoking were not identified as risk factors for AD, reinforcing the critical role of technical performance.

Concomitant temporary mechanical support in high-risk coronary artery bypass surgery.

OBJECTIVES: Patients with low left ventricular ejection fraction (LVEF) undergoing high-risk coronary artery bypass grafting (CABG) are at increased risk for postcardiotomy cardiogenic shock. This report describes planned concomitant microaxial temporary mechanical support (MA-TMS) device placement as a viable bridge-to-recovery strategy for high-risk patients receiving surgical revascularization. METHODS: A retrospective review was performed for all patients from October 2017 to May 2019 with low LVEF (<30%), New York Heart Association Class III or IV symptoms, and myocardial viability who underwent CABG with prophylactic MA-TMS support at a single institution (n = 13). RESULTS: Mean patient age was 64.8 years, and 12 patients (92%) were male. Eight patients (62%) presented with acute coronary syndrome. Mean predicted risk of mortality was 4.6%, ranging from 0.6% to 15.6%. An average of 3.4 grafts were performed per patient. Greater than 60% of patients were extubated within 48 hours and out-of-bed within 72 hours, and the average duration of MA-TMS was 5.7 days. Mean postoperative length of stay was 16.7 days. There were no postoperative myocardial infarctions or deaths. CONCLUSIONS: Prophylactic MA-TMS may allow safe and effective surgical revascularization for patients with severe left ventricular dysfunction who may otherwise be offered a durable ventricular assist device.

Del Nido cardioplegia for minimally invasive aortic valve replacement.

BACKGROUND: We analyzed the impact and safety of del Nido Cardioplegia (DNC) in patients undergoing minimally invasive aortic valve replacement (MIAVR). METHODS: We analyzed all isolated MIAVR replacements from 5/2013-6/2015 excluding re-operative patients. The approach was a hemi-median sternotomy in all patients. Patients were divided into two cohorts, those who received 4:1 crystalloid:blood DNC solution and those in whom standard 1:4 Buckberg-based cardioplegia (WBC) was used. One-to-one propensity case matching of DNC to WBC was performed based on standard risk factors and differences between groups were analyzed using chi-square and non-parametric methods. RESULTS: MIAVR was performed in 181 patients; DNC was used in 59 and WBC in 122. Case matching resulted in 59 patients per cohort. DNC was associated with reduced re-dosing (5/59 (8.5%) versus 39/59 (61.0%), P < 0.001) and less total cardioplegia volume (1290 ± 347 mL vs 2284 ± 828 mL, P < 0.001). Antegrade cardioplegia alone was used in 89.8% (53/59) of DNC patients versus 33.9% (20/59) of WBC patients (P < 0.001). Median bypass and aortic cross-clamp times were similar. Clinical outcomes were similar with respect to post-operative hematocrit, transfusion requirements, need for inotropic/pressor support, duration of intensive care unit stay, re-intubation, length of stay, new onset atrial fibrillation, and mortality. CONCLUSIONS: Del Nido cardioplegia usage during MIAVR minimized re-dosing and the need for retrograde delivery. Patient safety was not compromised with this technique in this group of low-risk patients undergoing MIAVR.

The Achilles' heel of left ventricular assist device therapy: right ventricle.

PURPOSE OF REVIEW: Many patients suffer from either persistent right ventricular failure (RVF) at the time of left ventricular assist device (LVAD) or have ongoing symptoms consistent with RVF during chronic mechanical circulatory support. The lack of long-term right ventricular assist devices (RVADs) has limited the impact that mechanical circulatory support can provide to patients with biventricular failure. We aim to review the entire spectrum of RVF in patients receiving LVADs and reflect on why this entity remains the Achilles' heel of LVAD therapy. RECENT FINDINGS: In the early postoperative period, LVAD implantation reduces right ventricle (RV) afterload, but RV dysfunction may be exacerbated secondary to increased venous return. With prolonged therapy, the decreased RV afterload leads to improved RV contractile function. Bayesian statistical models outperform previously published preoperative risk scores by considering inter-relationships and conditional probabilities amongst independent variables. Various echocardiographic parameters and the pulmonary artery pulsatility index have shown promise in predicting post-LVAD RVF. Recent publications have delineated the emergence of 'delayed' RVF. Several devices are currently being investigated for use as RVADs. SUMMARY: Post-LVAD RVF depends on the RV's ability to adapt to acute hemodynamic changes imposed by the LVAD. Management options are limited due to the lack of an easily implantable, chronic-use RVAD.