Right atriotomy closure with modified ventricular assist device ring.

BACKGROUND: Severe tricuspid regurgitation is a known risk factor for right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation and is often treated with concomitant tricuspid valve repair (TVR). The right atriotomy needed for exposure of the tricuspid valve may complicate early implantation of a durable right ventricular assist device, which may be needed if RVF persists. MATERIALS & METHODS: A 53-year-old male patient on Impella and extracorporeal life support was scheduled for LVAD implantation with concomitant TVR. RESULTS: We performed a technique for closure of the right atrium after TVR with a modified ventricular assist device ring to facilitate right ventricular support implantation if needed.

Inadvertent pacemaker lead dislodgement.

Transcatheter aortic valve implantation (TAVI) has become an established treatment option for aortic valve stenosis in patients with a high risk for conventional surgical valve replacement. A well-known complication is the development of conduction abnormalities. In the case of a new third-degree atrioventricular block, the complication can be life-threatening and permanent pacing is needed. Often these patients have a venous sheath placed in the jugular vein for the perioperative period. We report a case of inadvertent dislodgement of a permanent pacemaker lead after removal of a preoperatively placed venous sheath in a TAVI patient.

ECMELLA 2.0: Single Arterial Access Technique for a Staged Approach in Cardiogenic Shock.

The main drawbacks of venoarterial extracorporeal life support (VA-ECLS) for cardiogenic shock are incomplete left ventricular unloading with concomitant pulmonary edema and vascular access site complications. We describe the staged treatment technique for severe cardiogenic shock with a combination of the Impella 5.0/5.5 (Abiomed Inc, Danvers, MA) and peripheral ECLS (ECMELLA) using a single arterial access in 2 consecutive patients with refinement of the technique in the second case. The arterial cannula was inserted through the same vascular graft in the axillary artery that served as access for the previously implanted microaxial blood pump.

Single arterial access ECMELLA: A new concept and step-by-step procedure.

Therapy for cardiogenic shock using temporary mechanical circulatory support has improved significantly in the last decades, providing patients with new technologies for both acute phase stabilization and bridging to long-term therapies. A combination of a venoarterial extracorporeal life support system and the Impella left ventricular assist device (known as the ECMELLA approach) represents an effective therapy for severe cardiogenic shock that achieves high-flow circulatory support with simultaneous left-ventricular unloading. We present the new ECMELLA 2.0 concept, whereby a single arterial access technique is used to treat severe cardiogenic shock. The goal of this technique is to reduce access-related complications and make a bedside staged weaning from mechanical support possible.

On the function of biosynthesized cellulose as barrier against bacterial colonization of VAD drivelines.

Bacterial colonization of drivelines represents a major adverse event in the implantation of left ventricular assist devices (L-VADs) for the treatment of congestive heart failure. From the external driveline interface and through the skin breach, pathogens can ascend to the pump pocket, endangering the device function and the patient's life. Surface Micro-Engineered Biosynthesized cellulose (BC) is an implantable biomaterial, which minimizes fibrotic tissue deposition and promotes healthy tissue regeneration. The topographic arrangement of cellulose fibers and the typical material porosity support its potential protective function against bacterial permeation; however, this application has not been tested in clinically relevant animal models. Here, a goat model was adopted to evaluate the barrier function of BC membranes. The external silicone mantle of commercial L-VAD drivelines was implanted percutaneously with an intervening layer of BC to separate them from the surrounding soft tissue. End-point evaluation at 6 and 12 weeks of two separate animal groups revealed the local bacterial colonization at the different interfaces in comparison with unprotected driveline mantle controls. The results demonstrate that the BC membranes established an effective barrier against the bacterial colonization of the outer driveline interface. The containment of pathogen infiltration, in combination with the known anti-fibrotic effect of BC, may promote a more efficient immune clearance upon driveline implantation and support the efficacy of local antibiotic treatments, therefore mitigating the risk connected to their percutaneous deployment.

Incidence of acute type A aortic dissection in emergency departments.

Due to the symptoms, patients with acute type A aortic dissection are first seen by the ambulance service and diagnosed at the emergency department. How often an aortic dissection occurs in an emergency department per year has been studied. The incidence in the emergency department may be used as a quality marker of differential diagnostics of acute chest pain. A multi-institutional retrospective study with the municipal Berlin hospital chain Vivantes and its Department of Pathology and the Charité - University Medicine Berlin was performed. From the Berlin Hospital Society, the annual numbers of publicly insured emergency patients were obtained. Between 2006 and 2016, 631 aortic dissections were identified. The total number of patients treated in the emergency departments (n = 12,790,577) was used to calculate the "emergency department incidence." The autopsy data from six clinics allowed an estimate on how many acute type A aortic dissections remained undetected. Across all Berlin hospitals, the emergency department incidence of acute type A aortic dissection was 5.24 cases in 100,000 patients per year. In tertiary referral hospitals and, particularly, in university hospitals the respective incidences were markedly higher (6.7 and 12.4, respectively). Based on the autopsy results, about 50% of the acute type A aortic dissection may remain undetected, which would double the reported incidences. Among different hospital types the emergency department incidences of acute type A aortic dissection vary between 5.93/100,000 and 24.92/100,000. Aortic dissection; Incidence; Emergency Department; Epidemiology.

Externalized conductor of a Kentrox lead and an unexpected insulation failure.

Cardiac resynchronization therapy-defibrillator device upgrades may represent a challenging scenario, especially because unexpected findings can increase procedure difficulty. One such unexpected finding represents insulation failure with unremarkable device interrogation. Insulation failure due to an externalized conductor of an implantable cardiac defibrillator-lead has been recently described for the Kentrox lead (Biotronik). Another challenging aspect of device upgrades is the presence of venous thrombosis as in this case. Here, we report an inside-out abrasion of a Kentrox lead, an unexpected second insulation failure found during pocket revision and the successful recanalization in a patient with known left subclavian vein thrombosis.

Two implantable continuous-flow ventricular assist devices in a biventricular configuration: technique and results.

OBJECTIVES: No continuous-flow right ventricular assist device for long-term support is available at the moment. Two continuous-flow ventricular assist devices used in a continuous-flow biventricular assist device configuration is an emerging option which has proven its feasibility but still is not approved for routine use. We present our technique and results of modifying the left ventricular assist device and making it suitable for right ventricular support. METHODS: Between September 2009 and October 2017, 39 patients received implantation of a continuous-flow ventricular assist device for right ventricular support in a continuous-flow biventricular assist device configuration. For implantation of the HeartWare® manufacturers name of the pump HeartWare HVAD pump (HVAD)® centrifugal ventricular assist device, we performed 2 major modifications: banding of the outflow graft and reducing the intracaval length of the inflow cannula. The HVAD® could be safely implanted into the right atrium or ventricle. The HeartMate 3® left ventricular assist device needed no banding, but we increased the extraventricular part of the inflow cannula. RESULTS: The overall 30-day survival for the group receiving primarily a continuous-flow biventricular assist device was 72.7% (9.5% standard error of the mean (SEM)), and the 1-year survival was 45.0% (10.7% SEM). The overall 30-day survival for the group receiving a subsequent pump for right ventricular support in a continuous-flow biventricular assist device configuration after temporary right ventricular support was 71.4% (12.1% SEM), and 1-year survival was 40.8% (13.6% SEM). CONCLUSIONS: At the moment, there is a lack of a continuous-flow right ventricular assist device especially designed and approved for right ventricular support. Therefore, modifications in continuous-flow ventricular assist devices designed for the left ventricle are done to make them suitable for right ventricular support. However, more information is needed regarding the optimal surgical technique, patient selection and the optimal time point of implantation.

Enhanced L-type calcium currents in cardiomyocytes from transgenic rats overexpressing SERCA2a.

BACKGROUND: Previous research reported that transgenic rats overexpressing the sarco(endo)plasmic reticulum Ca(2+)-ATPase SERCA2a exhibit improved contractile function of the myocardium. Furthermore, impaired Ca(2+) uptake and reduced relaxation rates in rats with diabetic cardiomyopathy were partially rescued by transgenic expression of SERCA2a in the heart. OBJECTIVE: To explore whether enhanced Ca(2+) cycling in the cardiomyocytes of SERCA2a transgenic rats is associated with changes in L-type Ca(2+) (I(Ca-L)) currents. METHODS: The patch-clamp technique was used to measure whole-cell currents in cardiomyocytes from transgenic rats overexpressing SERCA2a and from wild-type (nontransgenic) animals. RESULTS: The amplitudes of I(Ca-L) currents at depolarizing pulses ranging from -45 mV to 0 mV (350 ms duration, 1 Hz) were significantly higher in cardiomyocytes of SERCA2a transgenic rats than in nontransgenic rats (1985±48 pA [n=32] versus 1612±55 pA [n=28], respectively). The inactivation kinetics of I(Ca-L) showed subtle differences with increased tau fast and tau slow decay constants in cardiomyocytes of SERCA2a transgenic animals. Beta-adrenergic stimulation with 50 nM isoproterenol reduced tau fast and tau slow decay constants in cardiomyocytes of transgenic rats to values that were not significantly different from those in normal cardiomyocytes. Furthermore, isoproterenol enhanced I(Ca-L) currents 3.2-fold and 2.3-fold in cardiomyocytes with and without the SERCA2a transgene, respectively, and this effect was abolished by buffering intracellular Ca(2+) with BAPTA. CONCLUSIONS: These findings indicate that enhanced Ca(2+) cycling in the hearts of SERCA2a transgenic rats, both under normal conditions and during beta-adrenergic stimulation, involves changes in I(Ca-L) currents. Modified I(Ca-L) kinetics may contribute, to some extent, to the improved contractile function of the myocardium of transgenic rats.