Emergent veno-venous extracorporeal membrane oxygenation during aortic valve replacement following severe re-expansion pulmonary edema: A case report.

Re-expansion pulmonary edema is defined as pulmonary edema that occurs when a chronically collapsed lung rapidly re-expands, most commonly following chest tube placement for pneumothorax, re-expansion of severe atelectasis, and evacuation of pleural effusion. Though it is very rare, the sudden onset and clinical features of re-expansion pulmonary edema make it a lethal complication that requires urgent treatment. We present a 60-year-old patient who underwent an aortic valve replacement with pre-existing large bilateral pleural effusions. Intraoperatively, upon evacuation of the pleural effusions, the patient developed worsening lung compliance, refractory hypoxemia, and hypercapnia that required emergent veno-venous extracorporeal membrane oxygenation support.

Transesophageal Echocardiography Assisting in the Identification of Intraabdominal Bleeding During Cardiac Surgery.

We present a case in which intraoperative transesophageal echocardiography (TEE) helped detect intraabdominal bleeding, a rare complication in cardiac surgery. A patient undergoing ascending aortic aneurysm and aortic valve repair had increasing vasopressor and transfusion requirement during sternal closure with TEE imaging revealing a nonspecific, hypoechoic fluid-like collection anterior to the stomach. Discussion between the anesthesiology and surgical teams prompted further investigation including a diagnostic laparoscopy which confirmed the presence of intraabdominal bleeding. Hemostasis was later achieved after identifying the source of bleeding from a pre-peritoneal vein and associated peritoneal defect adjacent to a mediastinal chest tube placed earlier in the operation.

Concomitant aortic valve repair for aortic insufficiency and implantation of left ventricle mechanical support.

BACKGROUND: Moderate to severe aortic valve insufficiency (AI) in patients undergoing left ventricular assist device (LVAD) implantation is a significant complication which occurs in up to 10.7% of patients in the INTERMACS database and has profound consequences for survival. Preoperative Impella use is associaed with greater post-LVAD AI. CASE PRESENTATION: 56 y/o Caucasian female with acute exacerbation of chronic congestive heart failure who needed urgent Impella placement followed by elective Heartmate III LVAD. CONCLUSION: Patients who have aortic valve regurgitation at the time of implantation have been handled by several methods, including aortic valve leaflets approximation, to aortic valve replacement or even valve closure. We report a case of geometric ring annuloplasty for repair of a regurgitant aortic valve during destination LVAD implantation.

Sleeve lobectomy: current indications and future directions.

Sleeve lobectomy was initially conceived as an alternative to pneumonectomy for patients with low-grade, centrally located lesions and limited cardiopulmonary reserve. Over the last several decades, advances in patient selection criteria and surgical techniques have allowed sleeve lobectomy to evolve from a compromise to pneumonectomy to first line intervention for centrally located lesions of all grades. Although more challenging than pneumonectomy, long-term outcomes and cost-effective measures favor sleeve lobectomy. The use of sleeve lobectomy has been expanded for locally advanced disease, and results remain superior to alternative procedures. Current literature has also shown evidence supporting the use of neoadjuvant treatment and minimally invasive techniques. It is likely that future results will continue to improve making sleeve lobectomy an even more attractive treatment option for qualifying patients.

Utility of virtual crossmatch in sensitized patients awaiting heart transplantation.

BACKGROUND: Organ transplant candidates with serum antibodies directed against human leukocyte antigens (HLA) face longer waiting times and higher mortality while awaiting transplantation. This study examined the accuracy of virtual crossmatch, in which recipient HLA-specific antibodies, identified by solid-phase assays, are compared to the prospective donor HLA-type in heart transplantation. METHODS: We examined the accuracy of virtual crossmatch in predicting immune compatibility of donors and recipients in heart transplantation and clinical outcomes in immunologically sensitized heart transplant recipients in whom virtual crossmatch was used in allograft allocation. RESULTS: Based on analysis of 257 T-cell antihuman immunoglobulin complement-dependent cytotoxic (AHG-CDC) crossmatch tests, the positive predictive value of virtual crossmatch (the likelihood of an incompatible virtual crossmatch resulting in an incompatible T-cell CDC-AHG crossmatch) was 79%, and the negative predictive value of virtual crossmatch (the likelihood of a compatible virtual crossmatch resulting in a compatible T-cell CDC-AHG crossmatch) was 92%. When used in a cohort of 28 sensitized patients awaiting heart transplantation, 14 received allografts based on a compatible virtual crossmatch alone from donors in geographically distant locations. Compared with the other 14 sensitized patients who underwent transplant after a compatible prospective serologic crossmatch, the rejection rates and survival were similar. CONCLUSION: Our findings are evidence of the accuracy of virtual crossmatch and its utility in augmenting the opportunities for transplantation of sensitized patients.

A clinical correlation study of severity of antibody-mediated rejection and cardiovascular mortality in heart transplantation.

BACKGROUND: The current International Society for Heart and Lung Transplantation (ISHLT) diagnostic criteria for antibody-mediated rejection (AMR) designate AMR as either absent (AMR 0) or present (AMR 1), without grading its severity. Yet, the extent of histologic and immunofluorescence (IF) findings of AMR varies across endomyocardial biopsies (EMBs). In this study, we hypothesized that the severity of AMR, as assessed on EMBs, correlates with cardiovascular mortality in heart transplant recipients. METHODS: All EMBs from 1985 to 2005 were evaluated. Biopsy specimens were uniformly studied by light microscopy and IF early post-transplant. A comprehensive vascular score (V1: no AMR, to V5: severe AMR) was prospectively assigned to each EMB, based on severity of both histologic and IF findings. Univariate Cox proportional hazards regressions were performed using indicators of vascular scores alone, combined, and cumulatively. RESULTS: Nine hundred six patients were transplanted and included in the study. Mean age was 46.6 +/- 15.5 years and 82% were male. A total of 26,236 EMBs comprised the study data. As expected, histologic and immunopathologic findings of AMR varied in severity. An incremental risk of cardiovascular mortality was found with more severe AMR whether vascular scores were analyzed individually (p = 0.001), in combination (p = 0.01) or cumulatively (p = 0.006). CONCLUSIONS: The severity of AMR on EMBs correlates with an incremental cardiovascular mortality risk after heart transplantation, suggesting that AMR should be viewed as a spectrum rather than just as present or absent. Supplementing the ISHLT AMR diagnostic guidelines with a consensus severity scale is warranted.

Effect of older donor age on risk for mortality after heart transplantation.

BACKGROUND: Despite the increasingly common use of donor hearts at least 50 years of age, controversy still remains regarding long-term outcome. Our goal was to determine if older donor age is associated with an increased risk of mortality and specifically if the use of donor hearts at least 50 years of age reduces survival. METHODS: We retrospectively studied records of all primary heart transplants performed between January 1990 and July 2002. Fifty-six patients who had received donor hearts at least 50 years of age were compared with 611 recipients of donor hearts less than 50 years of age. Clinicopathologic parameters were analyzed for their effect on mortality using the Cox proportional hazard model with calculation of hazard ratios (HR). Cut-point analysis of donor age was used to determine which donor age is associated with the greatest risk of mortality after transplant. RESULTS: Recipients of donor hearts at least 50 years of age were older (58.5 years +/- 7.0 vs 53.2 +/- 11.6; mean +/- standard deviation [SD]; p < 0.0001), suffered more often from ischemic cardiomyopathy (69% vs 50%, p = 0.01), and experienced a longer waiting time (192.2 days +/- 301.0 vs 138.6 +/- 190.8, p < 0.0001). Donor hearts at least 50 years of age (age 54.1 +/- 3.5 years) were more often female (50% vs 34%, p = 0.03), died less often of "head trauma" (9% vs 42%, p < 0.0001), and exhibited fewer cytomegalovirus (CMV) mismatches (29% vs 39%, p = 0.04) than donor hearts less than 50 years of age (age 26.8 +/- 12.3 years). Multivariate predictors of mortality were rejection index (HR 1.90 per unit [rejections/100 survival days], p < 0.0001), donor age (HR 1.16 per 10-year increment, p = 0.002), and recipient age (HR 1.24 per 10-year increment, p = 0.04). Recipients of donor hearts at least 50 years of age had reduced 1-year and 5-year survival ([65.7% vs 81.7%, p < 0.05] and [48.3% vs 68.4%, p < 0.05], respectively), as well as a higher proportion of deaths occurring within 1 month of transplant (41% of total deaths vs 23%, p = 0.06). Cut-point analysis indicated the characteristic of donor age of at least 40 years (categorical variable) to predict mortality with the same degree of fit as age used as a continuous variable. CONCLUSIONS: Although we observed a substantial reduction in survival among patients who were allocated donor hearts at least 50 years of age, this difference was not solely attributable to the categorical variable of donor age 50 in this group. Donor age as a continuous variable, however, was determined to be a notable predictor of survival and use of the donor age cut-point of 40 years (categorical variable) allowed risk stratification with similar accuracy. The use of a donor age cut-point of 40 years may be a useful clinical criterion for graft-related risk assessment.

Successful treatment of esophageal cancer with transhiatal esophagectomy after heart transplantation.

A 55-year-old heart transplant recipient with reflux esophagitis presented for routine endoscopic surveillance of an area of Barrett's metaplasia initially seen 3 years previously. Esophagogastroduodenoscopy revealed adenocarcinoma at 33 cm from the incisors. The preoperative clinical stage was T1N0M0 by endoscopic ultrasound. Transhiatal esophagectomy was performed with R0 resection of the cancer, and the patient recovered uneventfully. Pathologic examination confirmed esophageal adenocarcinoma (T1N0M0) in Barrett's mucosa. The patient is doing well, and has no evidence of disease after 18 months.

Off-pump technique for Thoratec left ventricular assist device insertion.

We present a case of left ventricular assist device (Thoratec; Thoratec Laboratories Corp, Pleasanton, CA) insertion performed through a left thoracotomy without cardiopulmonary bypass in a patient with severe end-stage congestive heart failure with renal and respiratory dysfunction and a history of multiple cardiac operations.