Ventricular assist device implantation in patients with a failing systemic right ventricle: a call to expand current practice.

Ventricular assist device (VAD) implantation is an established treatment modality for patients with end-stage heart failure, and improves symptoms and survival. In the Netherlands, it is not yet routinely considered in patients with congenital heart disease and failing systemic right ventricle (SRV). Recently, a VAD was implanted in 2 SRV patients, one who underwent a Mustard procedure during infancy for transposition of the great arteries (male, 47 years old) and one with a congenitally corrected transposition of the great arteries (male, 54 years old). The first patient is doing well >1 year after implantation; the second patient will be discharged home soon. These examples and other reports demonstrate the feasibility of adopting VAD implantation into routine care for SRV failure. In conclusion, patients with SRV failure may be suitable candidates for VAD implantation: they are relatively young, usually have a preserved subpulmonary left ventricular function, and their specific anatomical and physiological characteristics often make them unsuitable for cardiac transplantation. Therefore it is important to recognise the possibility of VAD implantation early in the process of SRV failure, and to timely refer these patients to a heart failure clinic with experience in VAD implantation in this group of patients for optimisation, screening, and implantation.

A cardiovascular simulator tailored for training and clinical uses.

OBJECTIVE: In the present work a cardiovascular simulator designed both for clinical and training use is presented. METHOD: The core of the simulator is a lumped parameter model of the cardiovascular system provided with several modules for the representation of baroreflex control, blood transfusion, ventricular assist device (VAD) therapy and drug infusion. For the training use, a Pre-Set Disease module permits to select one or more cardiovascular diseases with a different level of severity. For the clinical use a Self-Tuning module was implemented. In this case, the user can insert patient's specific data and the simulator will automatically tune its parameters to the desired hemodynamic condition. The simulator can be also interfaced with external systems such as the Specialist Decision Support System (SDSS) devoted to address the choice of the appropriate level of VAD support based on the clinical characteristics of each patient. RESULTS: The Pre-Set Disease module permits to reproduce a wide range of pre-set cardiovascular diseases involving heart, systemic and pulmonary circulation. In addition, the user can test different therapies as drug infusion, VAD therapy and volume transfusion. The Self-Tuning module was tested on six different hemodynamic conditions, including a VAD patient condition. In all cases the simulator permitted to reproduce the desired hemodynamic condition with an error<10%. CONCLUSIONS: The cardiovascular simulator could be of value in clinical arena. Clinicians and students can utilize the Pre-Set Diseases module for training and to get an overall knowledge of the pathophysiology of common cardiovascular diseases. The Self-Tuning module is prospected as a useful tool to visualize patient's status, test different therapies and get more information about specific hemodynamic conditions. In this sense, the simulator, in conjunction with SDSS, constitutes a support to clinical decision - making.

Xenon anaesthesia for patients undergoing off-pump coronary artery bypass graft surgery: a prospective randomized controlled pilot trial.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) surgery carries a high risk for haemodynamic instability and perioperative organ injury. Favourable haemodynamic effects and organ-protective properties could render xenon an attractive anaesthetic for OPCAB surgery. The primary aim of this study was to assess whether xenon anaesthesia for OPCAB surgery is non-inferior to sevoflurane anaesthesia with regard to intraoperative vasopressor requirements. METHODS: Forty-two patients undergoing elective OPCAB surgery were enrolled in this prospective, single-blind, randomized controlled pilot trial. Patients were randomized to either xenon (50-60 vol%) or sevoflurane (1.1-1.4 vol%) anaesthesia. Primary outcome was intraoperative noradrenaline requirements necessary to achieve predefined haemodynamic goals. Secondary outcomes included safety variables such as the occurrence of adverse events (intraoperatively and during a 6-month follow-up after surgery) and the perioperative cardiorespiratory and inflammatory profile. RESULTS: Baseline and intraoperative data did not differ between groups. Xenon was non-inferior to sevoflurane, as xenon patients required significantly less noradrenaline intraoperatively to achieve the predefined haemodynamic goals {geometric mean 428 [95% confidence interval (CI) 312, 588] vs 1702 [1267, 2285] µg, P<0.0001}. No differences were found for safety. Significantly more sevoflurane patients developed postoperative delirium (POD) (hazard ratio 4.2, P=0.044). The average arterial pressure was lower in the sevoflurane group {median75 [interquartile range (IQR) 6] vs 72 [4] mmHg, P=0.002}. No differences were found for other haemodynamic parameters, the respiratory profile and the perioperative release of inflammatory cytokines, troponin T, serum protein S-100ß and erythropoietin. CONCLUSIONS: Compared with sevoflurane, xenon anaesthesia allows a significant reduction in vasopressor administration in OPCAB surgery. Moreover, xenon anaesthesia was associated with a lower risk for POD, a finding that has to be confirmed in larger studies. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov (NCT01757106) and EudraCT (2012-002316-12).

20 years of arterial switch operation for simple TGA.

BACKGROUND: Arterial switch operation became the golden treatment for simple transposition of the great arteries (sTGA). We describe our experience with the arterial switch operation regarding long-term outcome and the need for re-intervention. Nevertheless, supravalvular pulmonary stenosis (SPS) remains a concern in the long run. We assess the evolution of SPS over time and evaluate the effect of technical modifications on SPS during our experience. METHODS: We performed a retrospective study on 133 patients operated with ASO for TGA between October 1991 and November 2009. Last report method was used. We reviewed our pediatric cardiology and cardiac surgery database to examine the echocardiographic data and electrocardiograms. A mean follow-up of 9.2 years (+/- 5.83 SD) was reached. RESULTS: One (0.8%) patient deceased postoperatively due to cardiogenic shock. The overall actuarial freedom from reoperation (open and percutaneous) was 88.1%, 78.5% and 76.9% at 1, 5 and 10 years. SPS needed to be treated in 17 patients. Valve regurgitation at final investigation was maximal moderate in 5 patients for the aortic valve, 10 for pulmonary valve and 3 in tricuspid valve. CONCLUSIONS: ASO shows excellent long-term results in sTGA with a very low morbidity and mortality and is therefore the procedure of choice. Re-intervention rate is determined by SPS. Since the extensive mobilization of the pulmonary arteries and the creation of a longer neo-pulmonary root, reduction in SPS was seen with no re-interventions in the second half of the group. To obtain a final comparison with the atrial switch operation, a longer Follow-up is necessary.

Infective endocarditis in patients after percutaneous pulmonary valve implantation with the stent-mounted bovine jugular vein valve: Clinical experience and evaluation of the modified Duke criteria.

AIMS: Percutaneous pulmonary valve implantation (PPVI) has proven good hemodynamic results. As infective endocarditis (IE) remains a potential complication with limited available clinical data, we reviewed our patient records to improve future strategies of IE prevention, diagnosis and treatment. METHODS: Medical records of all patients diagnosed with Melody® valve IE according to the modified Duke criteria were retrospectively analyzed in three Belgian tertiary centers. RESULTS: 23 IE episodes in 22 out of 240 patients were identified (incidence 2.4% / patient year) with a clear male predominance (86%). Median age at IE was 17.9 years (range 8.2-45.9 years) and median time from PPVI to IE was 2.4 years (range 0.7-8 years). Streptococcal species caused 10 infections (43%), followed by Staphylococcus aureus (n = 5, 22%). In 13/23 IE episodes a possible entry-point was identified (57%). IE was classified as definite in 15 (65%) and as possible in 8 (35%) cases due to limitations of imaging. Echocardiography visualized vegetations in only 10 patients. PET-CT showed positive FDG signals in 5/7 patients (71%) and intracardiac echocardiography a vegetation in 1/1 patient (100%). Eleven cases (48%) had a hemodynamically relevant pulmonary stenosis at IE presentation. Nine early and 6 late percutaneous or surgical re-interventions were performed. No IE related deaths occurred. CONCLUSIONS: IE after Melody® valve PPVI is associated with a relevant need of re-interventions. Communication to patients and physicians about risk factors is essential in prevention. The modified Duke criteria underperformed in diagnosing definite IE, but inclusion of new imaging modalities might improve diagnostic performance.

Partial mechanical long-term support with the CircuLite Synergy pump as bridge-to-transplant in congestive heart failure.

BACKGROUND: Full mechanical support with a left ventricular assist device (LVAD) is often limited to very sick patients, as the only survival option. This European multicenter study analyzes the effect of partial mechanical support as bridge-to-transplant in a less sick heart failure patient group. METHODS: The CircuLite Synergy device is implanted via a small right-sided thoracotomy with an inflow cannula in the left atrium and an outflow graft connected to the right subclavian artery without the use of extracorporeal circulation. The pump itself sits in a "pacemaker" pocket subcutaneously in the right clavicular groove. It is able to pump up to 3.0 l/min and partially unload the left ventricle. RESULTS: The device was implanted in 25 patients on the cardiac transplant waiting list (20 males), aged 55.5 +/- 9.6 yrs with an ejection fraction of 21.6 +/- 6.0 %, a mean arterial pressure of 73.5 +/- 8.5 mmHg, a pulmonary capillary wedge pressure of 27.2 +/- 7.8 mmHg and cardiac index of 1.9 +/- 0.4 l/min/m (2). Duration of support ranged from 6 to 238 days. Right heart catheterization showed significant hemodynamic improvement in the short- and intermediate-term after implantation with increases in arterial pressure from 72.6 +/- 11.0 to 79.4 +/- 8.6 mmHg ( P = 0.04) and in cardiac index from 2.0 +/- 0.4 to 2.7 +/- 0.6 l/min/m (2) ( P = 0.003) with a reduction in pulmonary capillary wedge pressure from 28.5 +/- 6.0 to 19.7 +/- 6.9 mmHg ( P = 0.012). CONCLUSIONS: The CircuLite Synergy device is a partial support pump, which is easy to implant and which provides hemodynamic benefits in bridging heart failure patients to cardiac transplant.

Late recovery of atrioventricular conduction after pacemaker implantation for complete heart block in congenital heart disease: fact or fluke?

OBJECTIVES: Pacemaker implantation is a standard recommendation for patients with persistent complete heart block with congenital heart disease. This study was performed to determine the incidence and clinical significance of late recovery of atrioventricular (AV) conduction following pacemaker implantation. METHODS: A retrospective study of patients with congenital heart disease needing pacemaker implantation was performed between 1977 and 2008 at our institution. The postoperative course of all patients with complete heart block, in whom a permanent pacemaker was implanted, was followed on a semi-annual basis by clinical follow-up. RESULTS: A total of 56 patients with complete heart block underwent pacemaker implantation. Indications for pacemaker implantation could be categorized in primary AV conduction block (n = 28 ; 50%) and surgically-induced AV conduction block (n = 28 ; 50%). After pacemaker insertion, recovery of AV conduction was recognized in two patients. The first patient was operated for atrial septal defect type ostium secundum with complete heart block preoperatively. AV block resolved 2 days after pacemaker implantation. The second patient underwent mitral valve replacement. Postoperatively, the patient developed second degree heart block, which progressed 3 years later into complete heart block. A recovery of AV conduction was seen 7.5 years later. In these patients, no late recurrence of complete heart block was found during follow-up after 8 and 4 months, respectively. CONCLUSIONS: Recovery of AV conduction was observed in one patient with primary AV conduction block and in one patient with complete heart block after congenital heart surgery. Lifelong cardiac pacing in these specific subsets of patients may not be necessary.

Transapical left ventricular access for difficult to reach interventional targets in the left heart.

OBJECTIVE: Interventional targets may be virtually "excluded" due to vascular access problems or complex previous surgical procedures. This study reviews our experience using transapical ventricular puncture to gain direct access to the systemic ventricle. PATIENTS: Patient 1 (74 years, 2 previous sternotomies), patient 2 (66 years, 5 previous sternotomies), and patient 5 (69 years, 3 previous sternotomies) with prosthetic valves had paravalvular mitral valve leaks. Patient 3 (6.3 years, 2 previous sternotomies) with an extracardiac Fontan conduit, had a significant residual leak after two previous surgical attempts of patch closure of a severely regurgitant right atrioventricular valve. Patient 4 (10 months) had failure of standard ablation of the posteroseptal region of the mitral valve with persistent life-threatening episodes of ventricular tachycardia. METHODS: Procedures were performed under general anesthesia. Entry site was percutaneous in three patients and in two (and one conversion) a mini-thoracotomy was used. Sheaths were placed (6 F) using standard Seldinger technique, followed by the procedure as required. Direct surgical closure of the puncture site was done in 4 patients and in patient 3, a percutaneous vascular occlusion device was used. RESULTS: Easy and immediate access was obtained in all patients. The paravalvular leaks were crossed within seconds and completely closed with Amplatzer occluders. In patient 3 the valve was crossed using a Brokenbrough needle and a 12-mm Amplatzer device was placed in the patch leak. Patient 4 was successfully ablated using a 7-F irrigated catheter endo- and epicardially. Complications were in the percutaneous puncture group: in one patient a coronary artery was punctured and in one a hemothorax developed. CONCLUSION: Direct left ventricular puncture offers a very useful alternative access site in selected patients to reach "inaccessible" targets for certain percutaneous interventions in patients where standard approaches may be impossible or difficult.

Therapy for foetal pericardial tumours: survival following in utero shunting, and literature review.

We report the first case of foetal pericardial teratoma, treated successfully in utero by pericardio-amniotic shunting, and review the relevant literature. Foetal treatment improves survival in case of hydrops. Foetal pericardio-amniotic shunting could possibly be an alternative to serial pericardiocentesis.

Surgical closure of the patent ductus arteriosus and its effect on the cerebral tissue oxygenation.

AIM: Surgical patent ductus arteriosus (PDA) ligation is considered after failure or contraindication of medical treatment. Till now ligation of the PDA has been associated with low morbidity and mortality although recently concerns have been raised about the possible association of ductal clipping and neurodevelopmental abnormalities later in life. By means of near-infrared spectroscopy (NIRS), we analysed the changes in the cerebral tissue oxygenation index (TOI) and fractional tissue oxygen extraction (FTOE) at the time of clipping as well as after clipping. METHOD: Ten preterm infants with a symptomatic PDA who underwent surgical ligation were continuously monitored for heart rate (HR), mean arterial blood pressure (MABP), peripheral oxygen saturation (SaO(2)) and TOI from 1 h before up to 1 h after clipping. FTOE and haemoglobin difference (HbD) were calculated. Changes in parameters at 5 min after ligation represent the effect of the clipping itself whereas changes up to 1 h-post-clipping represent the post-clipping effect. RESULTS: At the exact time of clipping, over the entire group, we found a significant increase in TOI of 2.9% (p = 0.037), in HbD of 12.5 micromol/l (p = 0.047) and in HR of 6.5 bpm (p = 0.012). FTOE significantly decreased by 0.02% (p = 0.013). One hour post-clipping, the cerebral and peripheral parameters were not significantly different from the control values before clipping. CONCLUSION: The ductal clipping in se has no negative effect on the cerebral oxygenation.

In vitro set-up of modified Blalock Taussig shunt: vascular resistance-flow relationship.

BACKGROUND: A modified Blalock-Taussig (mBT) shunt is an anastomosis created between the systemic and pulmonary arterial tree in order to improve pulmonary blood flow in neonates and children with congenital heart disease. The aim of this study was to assess vascular resistance-flow relationship in an in vitro set-up of a modified Blalock Taussig shunt. METHODS: A shunt set-up was constructed with the vessels of a sheep. A modified BT shunt was anastomosed between an innominate (brachiocephalic) and a right pulmonary artery. A Medos pump (ventricular assist device) was used to create pulsatile flow. Three different mean pulmonary artery flow rates (Q PA ) were applied. Once mean pulmonary and mean aortic flows (Q AO ) were fixed, shunt flow rates for twelve different pulmonary vascular resistances (R p ) were investigated. RESULTS: For all three pulmonary flow rates, the shunt flow decreased with increasing pulmonary resistance. In addition, systemic flow decreased compared to pulmonary flow. When pulmonary flow rate was set at 800 ml/min and aorta flow rate at 900 ml/min, the distribution of flow between pulmonary and systemic organs flow rates ranged between 69% - 70% and 30% - 31% respectively. Similarly, when both pulmonary and aorta flow rates were set at 900 ml/min, pulmonary and systemic organ flows ranged between 73% - 77% and 23% - 27% respectively. For pulmonary and aorta flow rates of 1000 ml/min and 900 ml/min, respectively, the distribution of flow between pulmonary and systemic organ flow rates varied between 79% - 83% and 17% - 21% respectively. CONCLUSION: Knowledge of the relationship between vascular resistances and flow in this surgically created in vitro mBT shunt set-up may be helpful in the clinical management of the patients whose survival is crucially dependent on the blood flow distribution between the pulmonary and systemic circulation.

Cancer After Heart Transplantation: A 25-year Single-center Perspective.

BACKGROUND: Cancer is a major cause of morbidity and mortality after heart transplantation. METHODS: We studied 541 heart transplant patients from a single center over a period of 25 years, with a mean follow-up of 10.7 years. We determined incidence, type, risk factors, and prognosis for cancer after heart transplantation. RESULTS: Cancer was diagnosed in 181 patients, at a mean of 7.7 years after transplantation. Cumulative incidence of cancer at 5, 10, and 20 years was 14%, 29%, and 60%, respectively. The most frequent cancers were spinocellular skin cancer (22%), basocellular skin cancer (19%), lung cancer (16%), lymphoma (11%) and prostate cancer (10%). Age at transplantation > 50 years (hazard ratio, 2.9; P < .001) and male recipient gender (hazard ratio, 1.7; P = .038) were significant risk factors for posttransplant malignancy on multivariate Cox proportional hazards analysis. Median patient survival after diagnosis of cancer was 2.9 years for patients with noncutaneous cancer, versus 13.1 years for patients with only skin cancer (P < .001).

Plasma leakage of oxygenators in ECMO depends on the type of oxygenator and on patient variables.

This study was conducted to identify the causes of plasma leakage of oxygenators in extra corporeal membrane oxygenation (ECMO). From 1996 through 2002, 91 oxygenators were used in 62 patients undergoing ECMO for respiratory and/or cardiac failure. Several types of oxygenators were used (Medtronic Maxima, Minima, PRF, Medos Hilite). Patient variables and variables related to the ECMO set-up were analysed for their relationship with oxygenator failure by a time related multiple regression analysis (Cox). Oxygenator failure occurred in 26% of the cases. The analysis identified the type of oxygenator (p=0.0016), younger patient age (p=0.04) and the number of oxygenators used (p=0.03) as the independent significant risk factors. The type of oxygenator used has the most overwhelming effect (significantly less leakage with the Medos Hilite). In conclusion, leakage of oxygenators is predominantly caused by the type of oxygenator used. Patient variables (younger age and the number of oxygenators used in one patient) are also significant and allude to an inflammatory process as underlying mechanism of plasma leakage.

Is return of angina after coronary artery bypass grafting immutable, can it be delayed, and is it important?

BACKGROUND: Because survival after either an operation or angioplasty is similar across a wide spectrum of coronary patients, lasting symptom relief assumes high priority. OBJECTIVES: The objectives of this observational clinical study were (1) to determine whether the return of angina is immutable; (2) to identify factors that might delay its return, and (3) to evaluate whether its return is predictive of subsequent adverse events. METHODS: The return of angina of any degree of severity and morbid events subsequent to its return were studied by multivariable time-related analyses in a consecutive series of 9600 patients who were undergoing primary isolated coronary bypass operations between 1971 and 1992. RESULTS: The freedom rate from return of angina was 94%, 82%, 61% and 38% at 1, 5, 10, and 15 years. Increased modest risk of early return of angina was associated with preoperative demographic, symptom, coronary and vascular disease variables but reduced by more extensive arterial grafting. The ever-increasing risk of late return of angina was associated with demographic, symptomatic, left ventricular function, and coronary disease variables and was related strongly to comorbidity but was weakly reduced by controllable surgical variables. After the return of angina, 10-year freedom rate from infarct and survival was 71% and 68% respectively. CONCLUSIONS: (1) The risk of angina return increases relentlessly after operation, so it is likely immutable. (2) Delay of late angina return by use of arterial grafting is clinically trivial; control of noncardiac comorbidity may be more effective. (3) Fortunately, the return of angina after coronary artery bypass grafting has minimal impact on survival and is not predictive of imminent infarct.

Organ perfusion with Hemopump device assistance with and without intraaortic balloon pumping.

OBJECTIVE: Our objective was to analyze the potential advantage of combining an intraaortic balloon pump with a transthoracic Hemopump device (Medtronic, Inc., Minneapolis, Minn.) (Nimbus Medical, Inc., Rancho Cordova, Calif.). METHODS: Twelve sheep underwent implantation of a transthoracic Hemopump device and an intraaortic balloon pump. In the first series (n = 6), we analyzed the influence of the counterpulsation on the performance of the Hemopump device. In the second group (n = 6), hemodynamic changes, myocardial wall thickening, organ perfusion, and myocardial perfusion (determined with colored microspheres) were analyzed under the following conditions: (1) control situation, (2) during application of coronary stenosis, (3) during support with the Hemopump device, and (4) during support with the Hemopump device combined with intraaortic balloon pump support. RESULTS: In the first series, we found that addition of counterpulsation reduced output with the Hemopump device by 11.1% +/- 6%. In the second series, it was shown that coronary stenosis significantly reduced contractility (rate of pressure change and wall thickening) but did not cause hemodynamic collapse. Myocardial blood flow was significantly reduced in the poststenotic subendocardial regions (mean subendocardial blood flow dropped from 78 +/- 33 to 24 +/- 17 ml/min/100 gm; p = 0.0486). Support with the Hemopump device alone improved the ratio of subendocardial to subepicardial blood flow, but endocardial underperfusion remained (analysis of variance, p < 0.001). The Hemopump device with an intraaortic balloon pump completely restored perfusion in poststenotic regions. Peripheral organ perfusion did not change during ischemia or mechanical support. CONCLUSIONS: The association of balloon counterpulsation with the Hemopump device reduces the Hemopump output by 11% and increases myocardial blood flow to ischemic regions. Perfusion to peripheral organs remains unaltered. The transthoracic Hemopump device combined with an intraaortic balloon pump is an ideal support system for the ischemic, failing heart.

Effects of failure of the right side of the heart and increased pulmonary resistance on mechanical circulatory support with use of the miniaturized HIA-VAD displacement pump system.

This experimental study was designed to assess the influence of failure of the right side of the heart or pulmonary hypertension, or both, on the performance of a novel miniaturized left ventricular assist device. In small-sized dogs (n = 50) ischemic global left ventricular failure was induced and support was provided by the HIA-VAD displacement pump (stroke volume 10 or 25 ml) installed as a left ventricular assist device. In three groups of animals (n = 10 each) pulmonary hypertension was created before induction of global left ventricular failure. During left ventricular assist device support temporary ischemic failure of the right side of the heart was induced in four groups of animals (n = 10 each). In the group subjected to left ventricular failure, support with the left ventricular assist device, and right ventricular failure during left ventricular assist, left atrial pressure and cardiac index were significantly lower than in the group subjected to left ventricular failure and left ventricular assist alone (2 +/- 6 versus 11 +/- 6 mm Hg and 1.6 +/- 0.4 versus 1.0 +/- 0.4 L/(min/m2), respectively, p < 0.05). In the group subjected to pulmonary hypertension, left ventricular failure, and left ventricular support, left atrial pressure dropped to values near zero but cardiac index remained unaltered as compared with results with the same regimen without pulmonary hypertension. However, when right ventricular failure was added (that is, pulmonary hypertension, left ventricular failure, left ventricular support, and right ventricular failure during support with the left ventricular assist device) left atrial pressure dropped to negative values (p < 0.05) and cardiac index progressively deteriorated. When, in an additional group of dogs, biventricular support was installed in the latter regimen, circulation was initially well supported but oxygenation deteriorated in 60% of cases. We conclude that (1) adequate right ventricular function was indispensable during support with the left ventricular assist device, (2) the combination of pulmonary hypertension and right ventricular failure led to the "low left ventricular assist device output syndrome," and (3) biventricular mechanical support in the presence of pulmonary hypertension may be complicated by the alveolar leakage syndrome.

Mechanical support with microaxial blood pumps for postcardiotomy left ventricular failure: can outcome be predicted?

OBJECTIVE: We sought to identify the indications of mechanical support in postcardiotomy left ventricular failure in patients who are unable to undergo transplantation. METHODS: From 1989 through 1997, 61 patients with postcardiotomy left ventricular failure beyond intra-aortic balloon pumping were assisted with the Hemopump cardiac assist system (Medtronic, Minneapolis, Minn). Their mean age was 64 +/- 8 years. Comorbidity was prevalent; 47% underwent cardiac massage before pump support, and evolving myocardial infarction was diagnosed in 43% before surgery. Multivariable logistic regression of data known at the moment of pump insertion was performed to identify the risk factors for mortality. RESULTS: Sixty-five percent of the patients were weaned from the device, but only 30% were discharged home. Cardiac index evolution during the first hours after pump insertion (P <.001) is the only independent predictor for possibility to wean from the device in the multivariable analysis. Acute renal failure is the only variable retained in the model for 90-day mortality. Device-related complications were far more frequent with the femoral (54%) than with the transthoracic (6%) cannula. Only 13% of the patients had bleeding complications. CONCLUSIONS: One third of the patients with postcardiotomy heart failure refractory to use of the intra-aortic balloon pump can be saved with the use of an endovascular axial flow pump. It is impossible to predict lethal outcome on preoperative data alone. The early hemodynamic response to support seems to be related to functional recovery of the heart and subsequent weaning from the device.

Femoral venoarterial extracorporeal membrane oxygenation for severe reimplantation response after lung transplantation.

Severe pulmonary reimplantation response after lung transplantation is not very common, although the mortality can be high. We present a patient who developed an extremely severe reperfusion injury after bilateral lung transplantation. Because of severe hypoxia and hemodynamic instability, despite aggressive ventilator settings, venoarterial extracorporeal membrane oxygenation (ECMO) was instituted using the femoral approach at the bedside. During ECMO, the patient developed a thoracic wall hematoma that was treated with transfusion alone. After 50 h of ECMO, his chest radiograph had dramatically improved, his oxygen need had been reduced to 50%, and he was successfully weaned from ECMO. Two years later, he is doing extremely well. Therefore, institution of ECMO using the femoral approach can be performed safely at the bedside in the ICU, and can be lifesaving in the context of a very severe reimplantation response after lung transplantation.