Cardiogenic shock and severe secondary mitral regurgitation successfully treated with transcatheter edge-to-edge repair: a case report.

Background: Cardiogenic shock (CS) associated with severe mitral regurgitation (MR) forebodes a high risk of morbidity and mortality. Transcatheter edge-to-edge repair (TEER) is a rapidly evolving technique for severe MR in haemodynamically stable patients. However, the safety and efficacy of TEER for severe MR in CS are not well established. Case summary: An 83-year-old male presented with dyspnoea and was hospitalized for heart failure. Chest X-ray revealed pulmonary oedema. Transthoracic echocardiography showed severely depressed ejection fraction (EF) with severe secondary MR. Right heart catheterization confirmed a low cardiac index. Diuretics and inotropes were administered. Due to persistent hypotension, we could not wean inotropes. The patient was deemed high risk for surgery by the heart team, and a decision was made to proceed with TEER with MitraClip. Under transoesophageal echocardiography and fluoroscopic guidance, two MitraClips were deployed sequentially. The MR grade was reduced to two mild jets subsequently. The patient was weaned off inotropes and eventually discharged. At the 30-day follow-up, he was participating in physical activities such as golf. Discussion: Cardiogenic shock complicated by severe MR carries high mortality. With severe MR, the forward stroke volume is lower than the stated EF leading to poor organ perfusion. Inotropes and/or mechanical circulatory support devices are paramount for initial stabilization; however, they do not treat underlying MR. Transcatheter edge-to-edge repair with MitraClip has been shown to improve survival in CS patients with severe MR in observational studies. However, prospective trials are lacking. Our case demonstrates the utility of MitraClip to treat severe secondary MR refractory to medical therapy in a CS patient. The heart team must evaluate risks and benefits of this therapy in CS patients.

Eight-year outcomes of aortic valve replacement with the Carpentier-Edwards PERIMOUNT Magna Ease valve.

INTRODUCTION: The Carpentier-Edwards PERIMOUNT Magna Ease valve is a third-generation bioprosthesis for aortic valve replacement (AVR). This is a postapproval study reporting on its 8-year outcomes. METHODS: Adults undergoing AVR with the Magna Ease valve between October 2007 and December 2012 were enrolled for this prospective, nonrandomized, single-arm, and multicenter study. Assessments occurred preoperatively, at hospital discharge, 6 months, 1 year, and annually thereafter for up to 8 years. Outcomes included safety endpoints, hemodynamic performance, and New York Heart Association (NYHA) functional class. RESULTS: Of the 258 study patients, 67.5% were in NYHA Class I or II, and 32.5% were in NYHA Class III or IV at baseline. Concomitant procedures were performed in 44.2%. Total follow-up was 1597.6 patient-years, and median follow-up was 7 years (interquartile range: 5.5-8.0 years). Eight years following AVR, the functional class remained improved from baseline with 93.9% in NYHA Class I/II and 6.1% in NYHA Class III; 38 deaths had occurred, 8 of which were valve related; freedom from all-cause mortality was 80.7% (95% confidence intervals: 74.9, 86.4); freedom from valve-related mortality was 95.8% (92.8, 98.8); freedom from reintervention, explant, major bleeding events, and structural valve deterioration was 89.8% (85.1, 94.6), 94.8% (91.7, 97.9), 85.1% (80.0, 90.1), and 90.1% (84.7, 95.4), respectively; effective orifice area was 1.5 ± 0.5 cm2 , the mean gradient was 14.8 ± 8.3 mmHg, and 88.6% of patients had no or trivial aortic regurgitation. CONCLUSIONS: This study demonstrated satisfactory safety and sustained hemodynamic and functional improvements at 8 years following AVR with the Magna Ease valve.

In a large-volume multidisciplinary setting individual surgeon volume does not impact LVAD outcomes.

BACKGROUND: In complex operations surgeon volume may impact outcomes. We sought to understand if individual surgeon volume affects left ventricular assist device (LVAD) outcomes. METHODS: We reviewed primary LVAD implants at an experienced ventricular assist devices (VAD)/transplant center between 2013 and 2019. Cases were dichotomized into a high-volume group (surgeons averaging 11 or more LVAD cases per year), and a low-volume group (10 or less per year). Propensity score matching was performed. Survival to discharge, 1-year survival, and incidence of major adverse events were compared between the low- and high-volume groups. Predictors of survival were identified with multivariate analysis. RESULTS: There were 315 patients who met inclusion criteria-45 in the low-volume group, 270 in the high-volume group. There was no difference in survival to hospital discharge between the low (91.9%) and high (83.3%) volume matched groups (p = .22). Survival at 1-year was also similar (85.4% vs. 80.6%, p = .55). There was no difference in the incidence of major adverse events between the groups. Predictors of mortality in the first year included: age (hazards ratio [HR]: 1.061, p < .001), prior sternotomy (HR: 1.991, p = .01), increasing international normalized ratio (HR: 4.748, p < .001), increasing AST (HR: 1.001, p < .001), increasing bilirubin (HR: 1.081, p = .01), and preoperative mechanical ventilation (HR: 2.662, p = .005). Individual surgeon volume was not an independent predictor of discharge or 1-year survival. CONCLUSION: There was no difference in survival or adverse events between high and low volume surgeons suggesting that, in an experienced multidisciplinary setting, low-volume VAD surgeons can achieve similar outcomes to their high-volume colleagues.

Clostridioides difficile-Associated Atypical Hemolytic-Uremic Syndrome Successfully Treated With Eculizumab: A Case Report and Literature Review.

Clostridioides difficile infection is a rare precipitant for patients to develop atypical hemolytic-uremic syndrome, of which the pathogenesis remains unclear. Previous reports suggest activation of cytokine storm from binding of cyotoxins A and B to colonic wall membranes. CASE SUMMARY: We present a case of a previously healthy 21-year-old woman who developed fulminant C. difficile colitis and atypical hemolytic-uremic syndrome requiring abdominal surgery and renal replacement therapy. She was ultimately treated with eculizumab without the use of plasmapheresis and remains in remission with full renal recovery. CONCLUSIONS: Our patient's significant response to terminal complement inhibitor, without the use of plasmapheresis, suggests that the underlying pathology is significantly driven by the alternative complement pathway. We propose that C. difficile-associated atypical hemolytic-uremic syndrome be defined as primary atypical hemolytic-uremic syndrome and strongly consider eculizumab as first-line therapy.

Combination plate and band fixation for primary closure in bilateral lung transplantation.

BACKGROUND: Sternal complications are common following transverse thoracosternotomy in patients undergoing bilateral lung transplantation. We present a single-institution experience using a next generation rigid fixation system for primary sternal closure following transverse sternotomy for bilateral lung transplantation. METHODS: Retrospective review was performed on all patients who had bilateral sequential lung transplants utilizing a transverse thoracosternotomy from 2016 to 2020. Demographics, baseline characteristics, peri-operative data, and outcomes were collected, reviewed and summarized. Two groups of patients were identified: wire cerclage (Group A), combination plate-and-band rigid fixation (Group B). The primary outcome was sternal complications, which were divided into mechanical and non-mechanical. RESULTS: Twenty-two patients met inclusion criteria. Three patients (13.6%) were in Group A, nineteen patients (86.4%) in Group B. Two patients in each Group A (66.6%) and Group B (10.5%) experienced a sternal complication. Sternal complications included sternal dehiscence (2), sternal malunion (1), and surgical site infection (1). One patient with plate-and-band fixation (5.2%) had a mechanical sternal complication. Three patients required reoperation secondary to sternal complication. CONCLUSIONS: The utilization of a combination plate-and-band rigid fixation system for primary closure is safe and may be an effective method to reduce sternal complications following transverse thoracosternotomy for lung transplantation.

Postcardiotomy extracorporeal membrane oxygenator: No longer a bridge to no where?

BACKGROUND: Postcardiotomy extracorporeal membrane oxygenation (PC-ECMO) represents a unique subset of critically ill patients, with a paucity of data regarding long-term survival and correlated characteristics. We present a retrospective cohort of PC-ECMO patients, with outcomes at 1 and 3 years. METHODS: Data were collected retrospectively for all patients requiring ECMO within 72 hours of an index cardiac operation (excluding assist devices and transplants). Primary outcomes were the ability to wean from ECMO, hospital survival, and long-term survival. RESULTS: Thirty-one patients required PC-ECMO, representing a total of 172 days of ECMO support. Overall survival data were the ability to wean 58%, hospital survival 52%, 1-month survival 42%. The estimated 12- and 36-month survival for all PC-ECMO patients was 35% and 29%, respectively. Twelve and 36-month survival for all hospital survivors was 62% and 56%. Operative times, the Society of Thoracic Surgeons risk scores, type of operation, open chest status, hemorrhage, and cannulation location, and timing were all compared. Centrally cannulated patients were more likely to wean from ECMO (83% vs 44%; P = .03), and survive hospitalization (75% vs 36%; P = .04) and trended toward long-term survival benefit (67% vs 33%; P = .06). Otherwise, no statistically significant relationships were observed. CONCLUSIONS: Central cannulation may provide benefits in the postcardiotomy patient, compared to peripheral strategies. Twelve and 36-month survival for all PC-ECMO patients was 35% and 29%. For hospital survivors, 12 and 36-month survival 62% 56% at 36. These data support PC-ECMO as a reasonable salvage strategy, with midterm survival comparable to other surgically treated diseases.

Recurrent pump thrombosis is common after axial continuous-flow left ventricular assist device exchange.

In selected patients with left ventricular assist device-associated infection or malfunction, pump exchange may become necessary after conservative treatment options fail and heart transplantation is not readily available. We examined the survival and complication rate in patients (⩾19 years of age) who underwent HeartMate II to HeartMate II exchange at our institution from 1 January 2010 to 28 February 2018. Clinical outcomes were analyzed and compared for patients who underwent exchange for pump thrombosis (14 patients), breach of driveline integrity (5 patients), and device-associated infection (2 patients). There were no differences in 30-day mortality (p = 0.58), need for temporary renal replacement therapy (p = 0.58), right ventricular mechanical support (p = 0.11), and postoperative stroke (p = 0.80) among groups. Survival at 1 year was 90% ± 7% for the whole cohort and 85% ± 10% for those who underwent exchange for pump thrombosis. In patients exchanged for device thrombosis, freedom from re-thrombosis and survival free from pump re-thrombosis at 1 year were 49% ± 16% and 42% ± 15%, respectively. No association of demographic and clinical variables with the risk of recurrent pump thrombosis after the first exchange was identified. Survival after left ventricular assist device exchange compares well with published results after primary left ventricular assist device implantation. However, recurrence of thrombosis was common among patients who required a left ventricular assist device exchange due to pump thrombosis. In this sub-group, consideration should be given to alternative strategies to improve the outcomes.

Can we expect improvements in outcomes with centrifugal vs axial flow left ventricular assist devices in patients transitioned from extracorporeal life support?

BACKGROUND: Several patient-related characteristics have been associated with inferior outcomes following durable left ventricular assist device (LVAD) implantation in patients transitioned from venoarterial extracorporeal membrane oxygenation (VA ECMO). The impact of LVAD pump type used is less well-known. METHODS: We compared outcomes between patents who received axial and centrifugal flow LVADs following stabilization with VA ECMO. RESULTS: From January 2011 to December 2018, we implanted 28 LVADs in patients transitioned from VA ECMO. This included 17 axial flow devices (HeartMate II LVAD, Abbott Laboratories, Chicago, IL) and 11 centrifugal flow pumps (eight HeartWare HVADs; Medtronic, Minneapolis, MN and three HeartMate 3 LVAS pumps; Abbott Laboratories, Chicago, IL). There was no difference in hospital mortality (23.5% vs 18.2%, P = .74) or 1-year survival (P = .31) between the devices. There were no differences in adverse event rates between the two pump types, apart from a higher rate of gastrointestinal bleeding in patients who received centrifugal flow pumps (1.44 events per 100 patient-months vs 14.67 events per 100 patient-months, P = .010). Preimplantation levels of alanine aminotransferase (hazard ratio [HR], 1.001; 95% confidence interval [CI], 1.000 to 1.002; P = .004) and elevated serum creatinine level (HR, 3.480; 95% CI, 1.121-10.807; P = .031) emerged as significant predictors of decreased 1-year survival. CONCLUSIONS: Preimplantation optimization of end-organ function is the single most important determinant of successful post-LVAD survival in patients transitioned from extracorporeal life support. There is no association of pump type with LVAD outcomes up to 1-year post implantation.

Role of Invasive Functional Assessment in Surgical Revascularization of Coronary Artery Disease.

In patients with stable coronary artery disease, percutaneous coronary intervention is associated with improved outcomes if the lesion is deemed significant by invasive functional assessment using fractional flow reserve. Recent studies have shown that a revascularization strategy using instantaneous wave-free ratio is noninferior to fractional flow reserve in patients with intermediate-grade stenoses. The decision to perform coronary artery bypass grafting surgery is usually based on anatomic assessment of stenosis severity by coronary angiography. The data on the role of invasive functional assessment in guiding surgical revascularization are limited. In this review, we discuss the diagnostic and prognostic significance of invasive functional assessment in patients considered for coronary artery bypass grafting. In addition, we critically discuss ongoing and future clinical trials on the role of invasive functional assessment in surgical revascularization.

Effect of diltiazem on exercise capacity after heart transplantation.

BACKGROUND: Sinus tachycardia (ST) is common after heart transplantation (HTx). The aim of the study was to evaluate the effect of diltiazem treatment during the first year after HTx on heart rate (HR), cardiac allograft function, and exercise capacity. METHODS: From the total cohort, 25 HTx recipients started diltiazem treatment 4±2 weeks after HTx and continued it for at least 1 year (diltiazem group). Each study case was matched to a control. All patients underwent hemodynamic assessment and cardiopulmonary exercise test (CPET) at 1 year after HTx. RESULTS: HR decreased in the diltiazem group from 99±11 bpm to 94±7 bpm (P=.03) and did not change in the controls (98±11 bpm vs 100±13 bpm, P=.14). The difference between the groups at 1 year after HTx was significant (P=.04). In the diltiazem group left ventricular (LV), stroke volume and ejection fraction increased (48±16 vs 55±17 mL, P=.02, and 60%±10% vs 62%±12% P=.03, respectively) but did not differ from controls. E/E' decreased (10.7±2.7 vs 7.3±1.9, P=.003) while cardiac index was higher (3.5±0.8 vs 3.1±0.5; P=.05) in the diltiazem group at 1-year follow-up. The absolute peak VO2 (21±4 vs 18±6 mL/kg/min; P=.05) and normalized peak VO2 (73%±17% vs 58%±14%; P=.004) were significantly higher in the diltiazem group. CONCLUSIONS: This study showed that diltiazem treatment reduces ST, may improve cardiac allograft function and exercise tolerance during the first year after HTx.

Surgical management of major intrathoracic hemorrhage resulting from high-risk transvenous pacemaker/defibrillator lead extraction.

A method, based on well-established trauma principles, is described for surgical management of serious intrathoracic bleeding complications that can occur during the extraction of pacemaker or defibrillator leads. Using this method, four patients who experienced rapid hemodynamic deterioration due to traumatic injury of the superior vena cava and its tributaries during defibrillator lead extraction underwent successful surgical repair. Perioperative preparation for high-risk lead extractions, management of major bleeding complications, and surgical repair techniques are discussed. Major bleeding complications can be managed effectively with this strategy leading to excellent overall success rates for extractions without mortality.

Three-dimensional bending, torsion and axial compression of the femoropopliteal artery during limb flexion.

High failure rates of femoropopliteal artery reconstruction are commonly attributed to complex 3D arterial deformations that occur with limb movement. The purpose of this study was to develop a method for accurate assessment of these deformations. Custom-made stainless-steel markers were deployed into 5 in situ cadaveric femoropopliteal arteries using fluoroscopy. Thin-section CT images were acquired with each limb in the straight and acutely bent states. Image segmentation and 3D reconstruction allowed comparison of the relative locations of each intra-arterial marker position for determination of the artery's bending, torsion and axial compression. After imaging, each artery was excised for histological analysis using Verhoeff-Van Gieson staining. Femoropopliteal arteries deformed non-uniformly with highly localized deformations in the proximal superficial femoral artery, and between the adductor hiatus and distal popliteal artery. The largest bending (11±3-6±1 mm radius of curvature), twisting (28±9-77±27°/cm) and axial compression (19±10-30±8%) were registered at the adductor hiatus and the below knee popliteal artery. These deformations were 3.7, 19 and 2.5 fold more severe than values currently reported in the literature. Histology demonstrated a distinct sub-adventitial layer of longitudinally oriented elastin fibers with intimal thickening in the segments with the largest deformations. This endovascular intra-arterial marker technique can quantify the non-uniform 3D deformations of the femoropopliteal artery during knee flexion without disturbing surrounding structures. We demonstrate that 3D arterial bending, torsion and compression in the flexed lower limb are highly localized and are substantially more severe than previously reported.

Fibrosing mediastinitis with severe bilateral pulmonary artery narrowing: RV-RPA bypass with a homograft conduit.

Although fibrosing mediastinitis is uncommon, it is a devastating sequela of certain granulomatous diseases. The compression of mediastinal structures can lead to severe cardiopulmonary symptoms. We report the case of a 50-year-old woman who presented with severe bilateral branch pulmonary artery compression 6 months after bilateral pulmonary artery stenting. We performed bypass surgery with use of a homograft conduit. Seven months postoperatively, the homograft and stent in the right pulmonary artery were patent, and the patient had resumed activities of daily living, including full-time employment. In addition to reporting this patient's case, we discuss surgery as an alternative to stenting in patients with fibrosing mediastinitis.

Postpartum rupture of the posteromedial papillary muscle.

We report a case of postpartum severe mitral regurgitation caused by papillary muscle rupture in a female with normal coronary arteries. The etiology of papillary muscle rupture was endocarditis from puerperal fever. Clinical stabilization was achieved with extracorporeal membrane oxygenation (ECMO) followed by mitral valve replacement two days later.

Synthesis, characterization and biocompatibility of "green" synthesized silver nanoparticles using tea polyphenols.

Since ancient times, people have taken advantage of the antimicrobial effects of colloidal silver particles. Aside from the medical prospects, silver nanoparticles are found in a wide range of commercially available consumer products ranging from cosmetics to household cleansers. Current synthetic methods for creating silver nanoparticles typically call for potentially hazardous chemicals, extreme heat, and produce environmentally dangerous byproducts. Therefore, it is essential that novel "green" synthesis of nanoparticles becomes a reality, and it is imperative to fully analyze the potential toxic effects of these nanoparticles. In this study, we have shown that by reducing silver nitrate in solutions of tea extract or epicatechin of varying concentrations, spherical silver nanoparticles were formed that had controllable size distributions depending on the concentration of tea extract or epicatechin in the samples. Our ultra-resolution microscopy demonstrated that the nanoparticles were in fact interacting with the keratinocytes. Furthermore, evaluation of mitochondrial function (MTS) to assess cell viability and membrane integrity (LDH) in human keratinocytes showed that the silver nanoparticles were nontoxic. These results demonstrated that these nanoparicles are potentially biocompatible and warrant further evaluation in other biological systems.

Sternal plating to prevent malunion of transverse sternotomy in lung transplantation.

Sternal malunion can be a significant cause of morbidity in double-lung transplantation when it is performed through a thoracosternotomy or clamshell incision. Some patients experience increased pain with malunion and have delayed or decreased functional recovery. We propose a method of sternal plating to decrease the incidence of sternal malunion encountered with this incision. The transverse sternotomy can be rigidly fixed with two titanium interlocking plates during chest closure, a procedure that offers the potential for timely and consistent union of the sternum. The interlocking plate configuration also affords a unique quality to this closure; a pin securing the two plates can be quickly released allowing expedient access to mediastinal structures if emergent re-entry is necessary.

Comparison of pleurodesis by erythromycin, talc, doxycycline, and diazepam in a rabbit model.

BACKGROUND: Patients with malignant pleural effusion, recurrent spontaneous pneumothorax, and recurrent benign pleural effusions may have significant relief of their symptoms with chemical pleurodesis. Talc is the most frequently used chemical sclerosant; however, it has been known to induce Adult Respiratory Distress Syndrome (ARDS). Other agents such as doxycycline and erythromycin have documented efficacy as sclerosing agents in the pleura, but they are not in widespread clinical use and have significant documented adverse reactions. Diazepam may represent a potential sclerosing agent in the pleura, because of its local inflammatory profile in other tissues. MATERIALS AND METHODS: Overall, 33 adult New Zealand White rabbits (Oryctolagus cuniculus) were randomized to 5 treatment groups. Each group received an intrapleural injection via 5 Fr silastic tubes of one of the following agents: 35-mg/kg erythromycin in 2 ml of saline, 70-mg/kg talc in 2 ml of saline, 10-mg/kg doxycycline in 2 ml of saline, 0.4-mg/kg diazepam in 2 ml of saline, or 2 ml of saline as a control. The animals were euthanized and necropsied 30 days after injection. The pleural surfaces were assessed for macroscopic and microscopic evidence of surrounding inflammation and fibrosis. RESULTS: Doxycycline resulted in severe pleural inflammation and fibrosis with pulmonary hemorrhage, whereas talc-treated animals had less effective fibrosis and granulomas. A trend toward higher mortality occurred in doxycycline-treated animals. Erythromycin demonstrated similar fibrosis (p=0.487) to doxycycline and had less inflammation (p<0.001). Diazepam treatment had little effect in the pleural cavity. CONCLUSIONS: This study demonstrates that erythromycin may be the ideal sclerosing agent. It had the advantage of maximal fibrosis with minimal inflammation. Although doxycycline was the most potent pleural sclerosant, it caused severe local tissue damage. Talc treatment resulted in only mild fibrosis, and diazepam was ineffective.