Staged left ventricular assist device reimplantation via the left anterior wall approach for a patient with severe pump pocket infection.

Pump pocket infection (PPI) is a refractory condition that can cause lethal complications in patients with a left ventricular assist device (LVAD). We report a case of PPI after LVAD implantation for ischemic cardiomyopathy that was successfully treated with staged pump reimplantation into the left ventricular anterior wall with the pedicled omental transfer. Major modification of the pump implantation site might be a useful strategy for local infection control of severe PPI.

Aortic thrombosis with visceral malperfusion during circulatory support with a combination of Impella and extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

Although veno-arterial extracorporeal membrane oxygenation (VA-ECMO) has been used to aid myocardial recovery in patients with postcardiotomy cardiogenic shock (PCCS), it has been associated with adverse effects. The combined use of VA-ECMO and Impella (ECPELLA) for PCCS, however, has been reported to be efficacious with few reports of thromboembolic events. We present a case of aortic thrombosis with visceral malperfusion during ECPELLA management for PCCS. We performed the Bentall procedure, mitral valve repair, tricuspid annuloplasty, and coronary artery bypass graft on a 73-year-old man admitted with congestive heart failure caused by annuloaortic ectasia, along with severe aortic and mitral regurgitation. VA-ECMO and Impella were required, since the cardiopulmonary bypass weaning was difficult. Impella was removed on postoperative day 4. On postoperative days 5 and 6, laboratory data showed worsening renal dysfunction, lactate levels, and acidosis. Contrast-enhanced computed tomography showed thrombosis in the celiac and superior mesenteric arteries. Aortic thrombectomy was performed. Hyperkalemia, caused by a reperfusion injury, resulted in ventricular fibrillation. Continuous hemodiafiltration improved the hyperkalemia. However, irreversible acidosis progressed, and the VA-ECMO flow rate could not be sustained. On postoperative day 7, the patient died. Perioperative use of Impella for PCCS may be effective in improving postoperative cardiac function. When sudden organ failure is observed after surgery, it is necessary to not only keep the exacerbation of cardiogenic shock in mind, but also the possibility of thrombosis.

Prognostic implications of preoperative chronic kidney disease and anemia in patients undergoing coronary artery bypass graft surgery.

PURPOSE: Chronic kidney disease (CKD) and anemia are independent preoperative risk factors for coronary artery bypass graft (CABG) surgery. We evaluated the implications of the coexistence of these two factors and their associated prognosis for CABG surgery. METHODS: We analyzed, retrospectively, consecutive patients who underwent elective CABG surgery between 2004 and 2014. The patients were classified into four groups depending on the presence or absence of preoperative CKD and anemia. We assessed the major adverse cardiac and cerebrovascular event (MACCE), defined as composite outcomes of cardio- and cerebrovascular death, revascularization through surgery or percutaneous intervention, hospitalization for congestive heart failure, and cerebral infarction. RESULTS: The study population consisted of 510 patients (73 % male; median age 71 years old), followed up for a median period of 2.8 years. Multivariate analysis indicated that neither the CKD/no-anemia group [hazard ratio (HR) 0.98, 95 % confidence interval (CI) 0.39-2.51, P = 0.973] nor the no-CKD/anemia group (HR 1.20, 95 % CI 0.69-2.09, P = 0.512) had significantly poorer prognoses than the no-CKD/no-anemia group. However, the CKD/anemia group had a significantly higher risk of a MACCE (HR 2.01, 95 % CI 1.01-3.98, P = 0.046). CONCLUSION: The presence of both CKD and anemia in patients undergoing CABG for coronary artery disease is synergistically associated with a worse outcome.

Aortic angioscopy assisted thoracic endovascular repair for chronic type B aortic dissection.

BACKGROUND: Non-obstructive general angioscopy is a powerful modality for detecting areas in the aorta with vulnerable plaque, which are difficult to visualize using conventional diagnostic tools such as computed tomography (CT). The aim of the present study was to clarify the efficacy and usefulness of aortic angioscopy in patients with chronic type B aortic dissection scheduled for thoracic endovascular repair (TEVAR). METHODS: Ten patients with chronic type B aortic dissection who underwent elective TEVAR were enrolled. Before starting the stent graft procedure, the aortic intima was observed by use of non-obstructive general angioscopy. Based on those findings, the range of the stent graft position was confirmed. RESULTS: In all patients, observations of the aortic intima with non-obstructive general angioscopy from a point just proximal of the descending aorta to the iliac artery were successful. At the proximal site, an entry site or ulcer-like projection was detected in all patients, while a small intimal tear or entry, or an irregular intima surface with a salmon-pink color were seen in some cases. In contrast, preoperative CT did not detect any such findings in the same locations. After confirming the position of the abnormal intima, we determined the position of the distal end of the stent graft. No complications considered to be related to aortic angioscopy were noted. CONCLUSIONS: Non-obstructive general angioscopy is useful for observing the condition of the aortic intima, revealing abnormal conditions, and confirming a normal aortic intima in patients with chronic type B aortic dissection. This modality may play an important role in determining the precise position of a stent graft for a TEVAR procedure.