Peri-operative fever and LVAD: SIRS or impaired right ventricular strain?

BACKGROUND: An inflammatory milieu after left ventricular assist device (LVAD) implantation is associated with multi-organ dysfunction and pre-operative heightened inflammatory state is associated with right ventricular failure after LVAD implantation. METHODS: We performed a retrospective analysis of 30 LVAD patients in our institution within the last 2 years for the development of fever and compared them to 30 non-LVAD open-heart surgery patients. RESULTS: Our results suggest that patients undergoing LVAD implantation are more likely to develop fever in the immediate post-operative period compared to other open-heart surgeries. This is independent of pharmacological treatment, age, or ethnical background. Females and obese patients were more likely to develop fever. CONCLUSION: Patients with right ventricular dysfunction, as demonstrated by elevated central venous pressure (CVP), had the strongest correlation with fever development. These results pose the question if there is a systemic inflammatory response-like phenomenon driven by increased right ventricular dysfunction.

Incidence of acute rejection and patient survival in combined heart-liver transplantation.

Combined heart-liver transplantation (CHLT) is indicated for patients with concomitant end-stage heart and liver disease or patients with amyloid heart disease where liver transplantation mitigates progression. Limited data suggest that the liver allograft provides immunoprotection for heart and kidney allografts in combined transplantation from the same donor. We hypothesized that CHLT reduces the incidence of acute cellular rejection (ACR) and the development of de novo donor-specific antibodies (DSAs) compared with heart-alone transplantation (HA). We conducted a retrospective analysis of 32 CHLT and 280 HA recipients in a single-center experience. The primary outcome was incidence of ACR based on protocol and for-cause myocardial biopsy. Rejection was graded by the International Society of Heart and Lung Transplantation guidelines with Grade 2R and higher considered significant. Secondary outcomes included the development of new DSAs, cardiac function, and patient and cardiac graft survival rates. Of CHLT patients, 9.7% had ACR compared with 45.3% of HA patients (p < 0.01). Mean pretransplant calculated panel reactive antibody (cPRA) levels were similar between groups (CHLT 9.4% vs. HA 9.5%; p = 0.97). Among patients who underwent testing, 26.9% of the CHLT and 16.7% of HA developed DSA (p = 0.19). Despite the difference in ACR, patient and cardiac graft survival rates were similar at 5 years (CHLT 82.1% vs. HA 80.9% [p = 0.73]; CHLT 82.1% vs. HA 80.9% [p = 0.73]). CHLT reduced the incidence of ACR in the cardiac allograft, suggesting that the liver offers immunoprotection against cellular mechanisms of rejection without significant impacts on patient and cardiac graft survival rates. CHLT did not reduce the incidence of de novo DSA, possibly portending similar long-term survival among cardiac allografts in CHLT and HA.

Predictors of in-hospital mortality and midterm outcomes of patients successfully weaned from venoarterial extracorporeal membrane oxygenation.

OBJECTIVES: There is limited evidence to guide the decision to proceed with weaning from venoarterial extracorporeal membrane oxygenation, and approximately 30% of patients weaned "successfully" do not survive to hospital discharge. We evaluated predictors of in-hospital mortality and midterm outcomes of patients successfully weaned from venoarterial extracorporeal membrane oxygenation after support for cardiogenic shock, surviving more than 24 hours after weaning, with the aim of improving patient selection for durable weaning. METHODS: We performed a retrospective analysis of 92 patients supported on venoarterial extracorporeal membrane oxygenation and successfully weaned between January 2013 and February 2018. Survival was estimated by the Kaplan-Meier method. Predictors of in-hospital mortality were identified using a Cox proportional hazards model and an Akaike information criterion-selected multivariate model. RESULTS: Overall survival at hospital discharge was 64.2%; survival was 54.6% 1 year after support and 51.4% 3 years after support. A history of diabetes, previous myocardial infarction, prolonged extracorporeal membrane oxygenation support, and hypoxemia at extracorporeal membrane oxygenation weaning were independent predictors of in-hospital mortality. At midterm follow-up, New York Heart Association class I heart function was observed in 53% of patients, class II in 19%, class III in 16%, and class IV in 12%. Average left ventricular ejection fraction was 46.5% ± 18.2%, and 50% of the patients had been readmitted to the hospital because of heart failure. CONCLUSIONS: Durable extracorporeal membrane oxygenation weaning with acceptable midterm functional status is obtainable in well-selected patients. Previous myocardial infarction, diabetes, prolonged extracorporeal membrane oxygenation support, and pulmonary dysfunction strongly predicted in-hospital mortality after venoarterial extracorporeal membrane oxygenation weaning. In this high-risk situation, other heart replacement therapies should be considered.

Mid-term outcomes with the use of extracorporeal membrane oxygenation for cardiopulmonary failure secondary to massive pulmonary embolism.

OBJECTIVES: There has been increasing interest in using extracorporeal membrane oxygenation (ECMO) to rescue patients with pulmonary embolism (PE) in the advanced stages of respiratory or haemodynamic decompensation. We examined mid-term outcomes and risk factors for in-hospital mortality. METHODS: We conducted a retrospective study of 36 patients who required ECMO placement (32 veno-arterial ECMO, 4 veno-venous) following acute PE. Survival curves were estimated using the Kaplan-Meier method. Risk factors for in-hospital mortality were assessed by logistic regression analysis. Functional status and quality of life were assessed by phone questionnaire. RESULTS: Overall survival to hospital discharge was 44.4% (16/36). Two-year survival conditional to discharge was 94% (15/16). Two-year survival after veno-arterial ECMO was 39% (13/32). In patients supported with veno-venous ECMO, survival to discharge was 50%, and both patients were alive at follow-up. In univariable analysis, a history of recent surgery (P = 0.064), low left ventricular ejection fraction (P = 0.029), right ventricular dysfunction ≥ moderate at weaning (P = 0.083), on-going cardiopulmonary resuscitation at ECMO placement (P = 0.053) and elevated lactate at weaning (P = 0.002) were risk factors for in-hospital mortality. In multivariable analysis, recent surgery (P = 0.018) and low left ventricular ejection fraction at weaning (P = 0.013) were independent factors associated with in-hospital mortality. At a median follow-up of 23 months, 10 patients responded to our phone survey; all had acceptable functional status and quality of life. CONCLUSIONS: Massive acute PE requiring ECMO support is associated with high early mortality, but patients surviving to hospital discharge have excellent mid-term outcomes with acceptable functional status and quality of life. ECMO can provide a stable platform to administer other intervention with the potential to improve outcomes. Risk factors for in-hospital mortality after PE and veno-arterial ECMO support were identified.

Lower-extremity complications with femoral extracorporeal life support.

OBJECTIVE: Patients undergoing emergency peripheral arteriovenous extracorporeal life support were evaluated for lower-extremity complications on the basis of the ipsilateral limb perfusion strategy. METHODS: In a retrospective review of patients receiving extracorporeal life support (2008-2013), 105 of 250 underwent femoral extracorporeal life support. For ipsilateral lower-extremity perfusion, patients underwent no superficial femoral artery cannulation (n = 35), percutaneous superficial femoral artery cannulation (n = 23), or open superficial femoral artery cannulation (n = 47). RESULTS: Patients' mean age was 50 ± 16 years, and 63% (n = 67) were male. A total of 92 patients (88%) had primary cardiac emergency, and 13 patients (12%) had cardiopulmonary emergency. The 30-day in-hospital mortality was 65% (n = 68), with an overall lower-extremity complication rate of 13% (n = 14). Lower-extremity complications were highest in the percutaneous superficial femoral artery (n = 6, 26%) and no superficial femoral artery (n = 7, 20%) groups (n = 1 [2%] in open superficial femoral artery group). In 2 group comparisons, the open superficial femoral artery group had significantly lower lower-extremity complications than the no superficial femoral artery (P = .02) and percutaneous superficial femoral artery (P = .004) groups. There was no difference between the no superficial femoral artery and percutaneous superficial femoral artery groups (P = .7). In the no superficial femoral artery group, emergency thromboembolectomy (n = 2), fasciotomy (n = 3), and emergency superficial femoral artery cannula placement (n = 2) were required. In the percutaneous superficial femoral artery group, thromboembolectomy with superficial femoral artery repair (n = 2), fasciotomy (n = 1), below-knee amputation (n = 1), open superficial femoral artery cannula revision (n = 1), and loss of distal signals from multiorgan failure (n = 1) were noted. In the open superficial femoral artery group, 1 patient had loss of signals from multiorgan failure. CONCLUSIONS: No superficial femoral artery perfusion strategy is associated with a high lower-extremity complication rate. If percutaneous cannulation is performed, then angiographic confirmation of superficial femoral artery run-off is highly recommended. The open superficial femoral artery approach remains a safe alternative to the other strategies.

Hypertrophic cardiomyopathy with restrictive phenotype and myocardial crypts.

This report describes a 22-year-old woman who has clinical and physiologic features of a restrictive cardiomyopathy. Magnetic resonance imaging showed myocardial delayed enhancement and interventricular septal crypts characteristic of hypertrophic cardiomyopathy (HCM). Transcatheter biopsy confirmed the diagnosis, revealing marked myocyte hypertrophy, interstitial fibrosis, and fiber disarray, which are findings consistent with HCM. A review of the literature suggests that this is the first case of HCM reported with a restrictive pattern and myocardial crypts.