Days Alive and Out of the Hospital After Heart Transplantation: A Retrospective Cohort Study.

OBJECTIVE: Evaluate days alive and out of the hospital (DAOH) as an outcome measure after orthotopic heart transplantation in patients with mechanical circulatory support (MCS) as a bridge to transplant compared to those patients without prior MCS. DESIGN: A retrospective observational study of adult patients who underwent cardiac transplantation between January 1, 2015, and January 1, 2020. The primary outcome was DAOH at 365 days (DAOH365) after an orthotopic heart transplant. A Poisson regression model was fitted to detect the association between independent variables and DAOH365. SETTING: An academic tertiary referral center. PARTICIPANTS: A total of 235 heart transplant patients were included-103 MCS as a bridge to transplant patients, and 132 direct orthotopic heart transplants without prior MCS. MEASUREMENTS AND MAIN RESULTS: The median DAOH365 for the entire cohort was 348 days (IQR 335.0-354.0). There was no difference in DAOH365 between the MCS patients and patients without MCS (347.0 days [IQR 336.0-353.0] v 348.0 days [IQR 334.0-354.0], p = 0.43). Multivariate analysis identified patients who underwent a transplant after the 2018 heart transplant allocation change, pretransplant pulmonary hypertension, and increased total ischemic time as predictors of reduced DAOH365. CONCLUSIONS: In this analysis of patients undergoing orthotopic heart transplantation, there was no significant difference in DAOH365 in patients with prior MCS as a bridge to transplant compared to those without MCS. Incorporating days alive and out of the hospital into the pre-transplant evaluation may improve understanding and conceptualization of the post-transplantation patient experience and aid in shared decision-making with clinicians.

First Use of a Novel Extracorporeal Life Support System: Successful Application in Tracheoesophageal Fistula Repair.

Extracorporeal life support, commonly referred to as extracorporeal membrane oxygenation (ECMO), is indicated when conventional medical and surgical measures fail to support a patient during cardiac or respiratory failure. Increased use of ECMO in recent years has led to innovation that has improved safety in appropriate candidates. This has resulted in the application of novel approaches to complex surgical problems. Herein, we describe a simple, novel, and new-to-market ECMO circuit used for successful perioperative veno-venous ECMO support of a patient undergoing complex repair of a tracheoesophageal fistula. We believe that this circuit and its use for intra-and post-operative extracorporeal support provides a framework for safe and simple ECMO support in the future, including perioperative support for patients undergoing complicated and challenging thoracic procedures.

Reversible cardiac dysfunction in severe COVID-19 infection, mechanisms and case report.

A previously healthy 49-year-old male patient presented with COVID-19 infection and required mechanical ventilation and extracorporeal membrane oxygenation due to severe hypoxemia. Echocardiography showed cardiac dysfunction with an apical sparing strain pattern, which rapidly normalized within a week. Apical sparing myocardial strain in patients with COVID-19 infection may suggest reverse-type stress cardiomyopathy.

Early Postoperative Aortic Root Thrombus After Heartmate 3.

As a bridge to heart transplantation or destination treatment, implantation of the Heartmate 3 (HM3) left ventricular assist device is a viable option for patients with end-stage congestive heart failure. The recent Momentum 3 trial has shown favorable outcomes compared with Heartmate 2. We report the first case of aortic root thrombus occurring early after HM3 implantation as a bridge to heart transplantation. Our case suggests that bridging with an Impella 5.0 preceding HM3 implantation could potentially predispose patients to aortic root thrombus after HM3 implantation, due to Impella-related injury to the aortic valve and aortic root stasis after durable LVAD support.

Left Ventricular Septal Hypertrophy in Elderly Patients With Aortic Stenosis.

OBJECTIVES: Left ventricular (LV) septal hypertrophy in aortic stenosis raises diagnostic and therapeutic questions. However, the etiology and clinical consequences of this finding have not been well studied. The aim of this study was to perform a morphologic evaluation of the LV in aortic stenosis and to investigate the contributing factors and consequences of septal hypertrophy. METHODS: Patients with moderate or severe aortic stenosis were prospectively enrolled. Patients with previous myocardial infarction, wall motion abnormalities, at least moderate valvular regurgitation, known cardiomyopathy, an LV ejection fraction of less than 50%, and age younger than 65 years were excluded. RESULTS: Forty-one patients underwent a final analysis. Septal hypertrophy (LV septal wall thickness ≥15 mm) was confirmed in 21 of 41 patients. The septal hypertrophy group had higher peak aortic valve velocity, a higher diabetes mellitus rate, and a higher rate and longer duration of hypertension than those without septal hypertrophy. The peak aortic valve velocity (odds ratio, 7.1; 95% confidence interval, 1.4-37.1) and diabetes mellitus (odds ratio, 7.4; 95% confidence interval, 1.2-46.2) were the significant factors associated with septal hypertrophy by multivariate analysis. Intraventricular conduction disturbance on electrocardiography was more frequent in the septal hypertrophy group (P = .021). CONCLUSIONS: Left ventricular septal hypertrophy was commonly observed in elderly patients with aortic stenosis, and a higher aortic valve velocity, hypertension, and diabetes mellitus were associated factors. Intraventricular conduction disturbance occurred more often in patients with septal hypertrophy than those without, which implies the pathophysiologic consequence. Further studies are needed to determine the impact of septal hypertrophy and intraventricular conduction disturbance on the prognosis of patients after aortic valve interventions.

Monster Lung Cavity in a Heart Transplant Recipient.

Invasive mucormycosis infections occur in less than 1% of recipients of orthotopic heart transplants. Given the angioinvasive nature of these infections, the mortality rate is high. Little literature exists regarding the presentation and management of these infections. We present a case of a patient who developed an infection after orthotopic heart transplant, describe the successful multidisciplinary management surrounding his care, and review the available literature regarding mucormycosis infections in heart transplant recipients.

Performance and Safety of an Integrated Portable Extracorporeal Life Support System for Adults.

Extracorporeal membrane oxygenation (ECMO) is indicated when conventional measures fail to support a patient during cardiac or respiratory failure. Due to the complicated nature of ECMO, patients often require transport to a tertiary care center. This study retrospectively compared the performance of the Cardiohelp™ (Maquet) life support system with a previously used ECMO circuit when transporting adult patients on venoarterial ECMO between facilities. Two ECMO circuits were compared for performance: 1) the Cardiohelp™ (Maquet) life support system and 2) the "standard" circuit consisting of a Thoratec CentriMag centrifugal pump, Maquet Quadrox-D oxygenator, and a Terumo CDI-500 in-line blood gas analyzer. After analyzing data from 16 patients (eight patients supported with each ECMO system), no differences in patient demographics, percentage of patients successfully weaned from ECMO, percentage of patients surviving to discharge, duration supported on the initial ECMO system, or total duration of ECMO were noted. No patient deaths were related to circuit failure or circuit disruptions in either group. Analysis of the performance of the ECMO circuits and the resulting patient status showed few significant differences between ECMO groups (Cardiohelp™ vs. standard circuit) and time points (the first 8 hours vs. a 24-hour time point). The statistically significant differences were not concerning in terms of appropriate medical support or patient safety. Of interest, the transmembrane pressure was significantly lower for the Cardiohelp™ module vs. the standard oxygenator during the first 8 hours (20.1 [5.3] vs. 37.1 [7.1] mmHg; p < .001) and at 24 hours (21.3 [3.8] vs. 34.8 [7.9] mmHg; p = .001). The Cardiohelp™ portable life support system provides safe and reliable support for adult patients on ECMO during interhospital patient transport as compared to the standard circuit.

Extracorporeal membrane oxygenation for general thoracic surgery: case series and narrative review.

Background and Objective: Extracorporeal membrane oxygenation (ECMO) has historically been utilized as a temporary life support option for patients with severe cardiac and pulmonary dysfunction. Recent advancements have enabled the safe application of ECMO in a wider variety of patients; we present a review of its use in patients undergoing general thoracic procedures supported by a case series at our institution. Methods: We review current literature focusing on ECMO applications in thoracic surgery outside of the traditional use. Additionally, we offer three cases of ECMO utilization to illustrate success stories and key lessons learned regarding the use of ECMO in general thoracic surgery. Key Content and Findings: Technologic advancements and enhanced safety profiles have enabled the safe application of ECMO in a wide array of patients far beyond the historic indications of cardiogenic shock and acute respiratory distress syndrome (ARDS). It is now feasible to consider ECMO for management of acute thoracic emergencies, as well as to better facilitate operative safety in complex general thoracic surgical procedures. Both venovenous and venoarterial ECMO can be utilized in carefully selected patients to provide cardiopulmonary support while enabling improved visualization and increased mobilization without concern for respiratory and/or cardiac compromise. Conclusions: Enthusiasm for the use of ECMO has increased in recent years. What was once considered a salvage therapy in cases of life-threatening cardiopulmonary decompensation now plays an increasingly important role in the safe conduct of complex thoracic surgery procedures, provides much needed time for organ recovery, and offers acute resuscitation options. This shift broadens our ability to deliver life-saving care to patients that previously would have otherwise had limited treatment options.

Regional perfusion during venoarterial extracorporeal membrane oxygenation: a case report and educational modules on the concept of dual circulations.

UNLABELLED: A challenging aspect of managing patients on venoarterial extracorporeal membrane oxygenation (V-A ECMO) is a thorough understanding of the relationship between oxygenated blood from the ECMO circuit and blood being pumped from the patient's native heart. We present an adult V-A ECMO case report, which illustrates a unique encounter with the concept of "dual circulations." Despite blood gases from the ECMO arterial line showing respiratory acidosis, this patient with cardiogenic shock demonstrated regional respiratory alkalosis when blood was sampled from the right radial arterial line. In response, a sample was obtained from the left radial arterial line, which mimicked the ECMO arterial blood but was dramatically different from the blood sampled from the right radial arterial line. A retrospective analysis of patient data revealed that the mismatch of blood gas values in this patient corresponded to an increased pulse pressure. Having three arterial blood sampling sites and data on the patient's pulse pressure provided a dynamic view of blood mixing and guided proper management, which contributed to a successful patient outcome that otherwise may not have occurred. As a result of this unique encounter, we created and distributed graphics representing the concept of "dual circulations" to facilitate the education of ECMO specialists at our institution. KEYWORDS: ECMO, education, cardiopulmonary bypass, cannulation.

Anterolateral papillary muscle rupture: an unusual complication of septic coronary embolism.

In most cases, acute mitral valve regurgitation in the setting of infective endocarditis is caused by the destruction of either the mitral valve leaflets or the chordal apparatus. A 54-year-old woman had development of respiratory failure due to pulmonary oedema from severe acute mitral valve regurgitation in the setting of acute bacterial endocarditis. She was found to have a ruptured anterolateral papillary muscle from occlusion of the circumflex artery by embolic vegetations arising from the aortic valve. Although this occurrence is uncommon, an embolic phenomenon resulting in myocardial infarction and subsequent rupture of papillary muscle must be considered as a cause of acute severe mitral valve regurgitation.

Thrombography reveals thrombin generation potential continues to deteriorate following cardiopulmonary bypass surgery despite adequate hemostasis.

The intrinsic and extrinsic activation pathways of the hemostatic system converge when prothrombin is converted to thrombin. The ability to generate an adequate thrombin burst is the most central aspect of the coagulation cascade. The thrombin-generating potential in patients following cardiopulmonary bypass (CPB) may be indicative of their hemostatic status. In this report, thrombography, a unique technique for directly measuring the potential of patients' blood samples to generate adequate thrombin bursts, is used to characterize the coagulopathic profile in post-CPB patients. Post-CPB hemostasis is typically achieved with protamine reversal of heparin anticoagulation and occasionally supplemented with blood product component transfusions. In this pilot study, platelet poor plasma samples were derived from 11 primary cardiac surgery patients at five time points: prior to CPB, immediately post-protamine, upon arrival to the intensive care unit (ICU), 3 hours post-ICU admission, and 24 hours after ICU arrival. Thrombography revealed that the Endogenous Thrombin Potential (ETP) was not different between [Baseline] and [PostProtamine] but proceeded to deteriorate in the immediate postoperative period. At the [3HourPostICU] time point, the ETP was significantly lower than the [Baseline] values, 1233 +/- 591 versus 595 +/- 379 nM.min (mean +/- SD; n=9, p < .005), despite continued adequacy of hemostasis. ETPs returned to baseline values the day after surgery. Transfusions received, conventional blood coagulation testing results, and blood loss volumes are also presented. Despite adequate hemostasis, thrombography reveals an underlying coagulopathic process that could put some cardiac surgical patients at risk for postoperative bleeding. Thrombography is a novel technique that could be developed into a useful tool for perfusionists and physicians to identify coagulopathies and optimize blood management following CPB.

Cardiac Transplantation and Consecutive Minimally Invasive Pectus Excavatum Repair.

Pectus excavatum is a common chest wall deformity with inward deviation of sternum and accompanying ribs. The depression can cause symptomatic cardiac compression, although the cardiopulmonary impact remains controversial. We present 2 cases of cardiac transplantation followed by modified minimally invasive pectus excavatum repair due to the hemodynamic consequences of the pectus deformity.

Practical Considerations for and Outcomes of Interfacility ECMO Transfer of Patients With COVID-19 During a Pandemic: Mayo Clinic Experience.

Interfacility transport of a critically ill patient with acute respiratory distress syndrome (ARDS) may be necessary for a higher level of care or initiation of extracorporeal membrane oxygenation (ECMO). During the COVID-19 pandemic, ECMO has been used for patients with severe ARDS with successful results. Transporting a patient after ECMO cannulation by the receiving facility brings forth logistic challenges, including availability of adequate personal protective equipment for the transport team and hospital capacity management issues. We report our designated ECMO transport team's experience of 5 patients with COVID-19-associated severe ARDS after cannulation at the referring facility. Focusing on transport-associated logistics, creation of checklists, and collaboration with emergency medical services partners is necessary for safe and good outcomes for patients while maintaining team safety.

Nontraditional implantable cardioverter defibrillator placement in adult patients with limited venous access: a case series.

BACKGROUND: Conventional transvenous approaches for implantable cardioverter defibrillator (ICD) lead placement are not possible in some patients with limited venous access or severe tricuspid valve dysfunction. METHODS: We retrospectively identified six patients who underwent ICD placement or revision requiring nontraditional alternative surgical lead placement at our institution between November 2006 and August 2008. The baseline and operative patient characteristic data were accumulated and reviewed. RESULTS: All the patients (mean age 71 +/- 3.4 years) underwent nontraditional surgical placement of epicardial ICD leads and traditional placement of ventricular epicardial bipolar pacing/sensing leads. Five patients had the distal lead tip fixed to the anterior epicardium of the right ventricular outflow tract, which was then looped under and around the ventricles, forming a "sling," and tunneled to a left subclavicular pocket. One patient had a single unipolar subcutaneous array lead fashioned into a "loop" and placed under the inferior aspect of the ventricles. The average procedure time was 311 +/- 115 minutes with a mean defibrillatory threshold (DFT) of < or = 22 + 3 J. Post-procedure hospitalization was 9.3 +/- 4.4 days and no device-related complications were encountered. Mean device follow-up of 451 + 330 days showed normal function and two appropriate successful ICD discharges. CONCLUSION: Nontraditional alternative surgical methods for the placement of ICD systems in adult patients with limited venous access or TV dysfunction can achieve results similar to those of conventionally placed endovascular leads with limited complications and comparable DFTs in short-term follow-up.

Development of advanced conduction disturbances following balloon-expandable transcatheter aortic valve replacement leads to poorer clinical outcomes.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is a reliable method of treating patients with severe aortic stenosis, but is associated with postprocedure conduction defects. OBJECTIVE: The purpose of this study was to compare clinical outcomes in patients who developed advanced conduction defects post-TAVR to those who did not. METHODS: We conducted a retrospective chart review of 243 patients who underwent balloon-expandable TAVR with the Edwards Sapien valve to determine the incidence of advanced conduction defects in our cohort. We compared clinical outcomes including overall mortality, improvement in symptomatology, and improvement in left ventricular ejection fraction. RESULTS: Among the 243 patients included in the study, 9.1% (22/243) required permanent pacemaker (PPM); 19.8% (48/243) developed left bundle branch block (LBBB), and 71.2% (173/243) did not develop any permanent advanced conduction defects. Overall 1-year mortality was similar across all three groups. There was significant improvement in New York Heart Association functional capacity of all groups post-TAVR, but this was much less in the PPM group (45.5% vs 68.8%, P = .04). Postprocedure from TAVR, patients with LBBB or PM were less likely to have improvement in their ejection fraction (net loss of -0.7% for LBBB and -5.7% for PPM compared to a net gain of 2.3% for no-LBBB/PM (P = .02). CONCLUSION: Patients who develop LBBB or require PM post-TAVR with Edwards Sapien valves are less likely to improve New York Heart Association functional capacity and more likely to have no improvement or deterioration of their pre-TAVR left ventricular ejection fraction.

What Drives Opioid Prescriptions After Cardiac Surgery: Practice or Patient?

BACKGROUND: The objectives of this study were to describe opioid prescribing after hospitalization for elective cardiac operation, to identify factors associated with increased opioid prescriptions, and to develop procedure-specific opioid prescribing guidelines. METHODS: We analyzed data from all adults (≥18 years) undergoing elective cardiac operation for acquired heart disease from July 2014 to March 2017 at 3 affiliated hospitals. Opioid prescription data were abstracted and converted to morphine milligram equivalents (MME). Multivariable logistic regression was performed with the outcome of top-quartile prescriptions. RESULTS: There were 4145 study patients after exclusion of preoperative opioid users (10.5%). Mean ± SD patient age was 63.9 ± 13.2 years, and 68.4% (n = 2835) were male. The operation was the first in 87.3% (3617); the most common operative approach was sternotomy in 91.0% (n = 3773), followed by robot-assisted operation in 4.6% (n = 192). The majority of patients, 72.7%, received an opioid prescription at hospital dismissal, with a median opioid prescription of 200 MME (interquartile range 0 to 375 MME; range 0 to 6400 MME). This varied by hospital, with medians of 150, 450, and 600 MME (P < .001). On multivariable analysis, the factor with greatest association with top-quartile opioid prescription was hospital (odds ratio, 57.2, highest vs lowest; 95% confidence interval, 40.2-81.4; P < .001). CONCLUSIONS: Significant variation in opioid prescribing practices after cardiac operation was observed. The primary driver was hospital-centric as opposed to patient specific. Opioid prescribing guidelines were established to standardize posthospital pain management.

Machine learning helps predict long-term mortality and graft failure in patients undergoing heart transplant.

OBJECTIVE: We aimed to develop a risk prediction model using a machine learning to predict survival and graft failure (GF) 5 years after orthotopic heart transplant (OHT). METHODS: Using the International Society of Heart and Lung Transplant (ISHLT) registry data, we analyzed 15,236 patients who underwent OHT from January 2005 to December 2009. 342 variables were extracted and used to develop a risk prediction model utilizing a gradient-boosted machine (GBM) model to predict the risk of GF and mortality 5 years after hospital discharge. After excluding variables missing at least 50% of the observations and variables with near zero variance, 87 variables were included in the GBM model. Ten fold cross-validation repeated 5 times was used to estimate the model's external performance and optimize the hyperparameters simultaneously. Area under the receiver operator characteristic curve (AUC) for the GBM model was calculated for survival and GF 5 years post-OHT. RESULTS: The median duration of follow-up was 5 years. The mortality and GF 5 years post-OHT were 27.3% (n = 4161) and 28.1% (n = 4276), respectively. The AUC to predict 5-year mortality and GF is 0.717 (95% CI 0.696-0.737) and 0.716 (95% CI 0.696-0.736), respectively. Length of stay, recipient and donor age, recipient and donor body mass index, and ischemic time had the highest relative influence in predicting 5-year mortality and graft failure. CONCLUSION: The GBM model has a good accuracy to predict 5-year mortality and graft failure post-OHT.

Inhaled nitric oxide mitigates need for extracorporeal membrane oxygenation in a patient with refractory acute hypoxemic respiratory failure due to cardiac and pulmonary shunts.

We present a case of refractory acute hypoxemic respiratory failure due to influenza B pneumonia with concomitant large intra-atrial shunt (IAS) and severe pulmonary regurgitation in a patient with Saethre-Chotzen syndrome with prior pulmonary homograft placement. Our patient's hypoxemia improved with inhaled nitric oxide as an adjunct to mechanical ventilation without requiring extracorporeal membrane oxygenation, and eventually a percutaneous closure with a 30 mm CardioSeal patent foramen ovale closure device was accomplished. However, his peri-procedural hospital course was complicated by occluder device migration, which was retrieved with eventual surgical closure of the PFO. Nitric oxide has not demonstrated any statistically significant effect on mortality and only reported to transiently improved oxygenation in patients with hypoxemic respiratory failure. Our case demonstrates that inhaled nitric oxide may have a role in acute hypoxemic respiratory failure in a case with significant cardiac and pulmonary shunts.

Descending aortic replacement after Nuss for pectus excavatum in a Marfan patient-Case report.

INTRODUCTION: The Nuss procedure for pectus excavatum (PE) repair has been successfully performed in Marfan syndrome (MFS) patients however there is concern for future risk of aortic dilation/rupture and need for emergent access with support bars in place. CASE PRESENTATION: We present a 45 year-old male with MFS that required descending aortic replacement shortly after modified Nuss repair. DISCUSSION: The majority of MFS patients have severe PE and repair with the Nuss procedure is not uncommon. The risk for life threatening aortic dilation, dissection, or rupture in such patients is a concern when utilizing this technique. Our work has been reported in line with the CARE criteria. CONCLUSION: Nuss repair should be considered in MFS patients with technique modifications and careful consideration of future risk of aortic dilation and rupture.