RESUMO
Limited donor organ availability often necessitates mechanical circulatory support, and recently the Impella 5.5, as a bridge to heart transplant. Of 175 Impella 5.5-supported patients at our institution, 45 underwent transplantation in the largest series to date, for whom we analyzed outcomes. Two methods of complete device explant were evaluated: central Impella transection and removal via axillary graft. Median Impella days were 25 (16-41); median waitlist days were 21 (9-37). Eighty-nine percent (40/45) of patients had device placement via right axillary artery. Seventy-six percent (34/45) underwent central transection for device removal. Four patients (8.9%) required short-term venoarterial extracorporeal membranous oxygenation (VA ECMO) postoperatively for primary graft dysfunction (PGD). Two patients (4.4%) suffered postoperative stroke. Five patients (11.1%) required new RRT postoperatively. One patient (2.2%) returned to the operating room (OR) for axillary graft bleeding. A higher chance of procedural complications was found with the axillary removal technique ( p = 0.014). Median intensive care unit (ICU) days, length of stay (LOS), and postoperative days to discharge were 46 (35-63), 59 (49-80), and 18 (15-24), respectively. Ninety-eight percent (44/45) survived to discharge. Thirty-day survival was 95.6% (43/45), with 1 year survival at 90.3% (28/31). Eighty-eight percent (37/42) remain without rejection. In our institutional experience, Impella 5.5 is a safe and reliable bridge to transplant.
Assuntos
Remoção de Dispositivo , Transplante de Coração , Coração Auxiliar , Humanos , Pessoa de Meia-Idade , Masculino , Feminino , Remoção de Dispositivo/métodos , Remoção de Dispositivo/estatística & dados numéricos , Adulto , Idoso , Estudos Retrospectivos , Oxigenação por Membrana Extracorpórea/métodos , Resultado do TratamentoRESUMO
Classic Impella exchange interrupts flow when the old device is pulled into the aorta before advancing the new device across the aortic valve, threatening circulatory collapse and loss of left ventricular access. In "double barrel," uninterrupted Impella exchange, the new device is placed into the ventricle alongside the old, where flow is first transitioned completely. Of 31 consecutive patients undergoing this procedure, none experienced intraoperative cardiac arrest, and 96.8% (30/31) had no new aortic insufficiency. One vascular complication ensued following known preoperative iliac injury. One patient suffered nonembolic stroke; another had subarachnoid hemorrhage. Fifty-five percent (17/31) of patients survived, with 22.6% (7/31) recovering, 25.8% (8/31) undergoing transplant, and 6.5% (2/31) transitioning to durable left ventricular assist device. Impella-only survival (83.3%, 10/12) was significantly higher than Impella-extracorporeal membrane oxygenation survival (36.8%, 7/19; (operating room) OR 14.46, 95% ((confidence interval) CI 1.74-119.93, p = 0.01). We conclude the "double barrel" technique is reliable in device-dependent cardiogenic shock patients, offering significant advantages and minimal risk.
RESUMO
Iatrogenic innominate vein injuries are rare complications associated with internal jugular venous catheters. These complications are accompanied by high morbidity and mortality rates in patients with severe underlying medical conditions. Without proper treatment, emergency surgery may be needed due to acute cardiac tamponade or hemothorax. Endovascular repair can be advantageous for patients with significant medical comorbidities. Herein, we report the case of a 62-year-old female with an iatrogenic injury to the innominate vein at the subclavian vein and internal jugular confluence due to a malpositioned left internal jugular catheter. A customized fenestrated endograft was positioned with fenestration oriented to the internal jugular vein and a new tunneled catheter was inserted across the fenestration into the superior vena cava upon removal of the malpositioned catheter. In addition, a brachio-basilic arteriovenous fistula was created. At one month follow-up, the patient had a palpable thrill over the arteriovenous fistula and a functioning tunneled catheter.
RESUMO
A 31-year-old woman was admitted to the emergency department with a stab wound to the heart. She was initially stable but rapidly developed hypotension. While the operating room and staff were in preparation, she underwent pericardiocentesis. She was then rushed to the operating room by the general surgical trauma team, who performed a bilateral anterior thoracotomy to control the bleeding. In the recovery room, the patient was still hypotensive, so cardiothoracic surgery was consulted. An echocardiogram revealed severe hypokinesis of both ventricles. The cardiothoracic surgeons returned her to the operating room and discovered that the anterior pericardium had been completely removed by the trauma team. This had caused the posterior pericardium to form a "bowstring" that almost totally obstructed pulmonary venous return and restricted right ventricular outflow of blood, inducing right-sided heart failure. This pericardial string also strangulated the left atrium posteriorly, forming 2 compartments. We repositioned the patient's heart and implanted ventricular assist devices bilaterally to provide temporary circulatory support. The patient made a good recovery. We suggest that bilateral assist device placement can be beneficial in the recovery of a stunned but otherwise normal heart.
Assuntos
Traumatismos Cardíacos/complicações , Técnicas Hemostáticas/efeitos adversos , Hérnia/etiologia , Hipotensão/etiologia , Toracotomia/efeitos adversos , Ferimentos Perfurantes/complicações , Adulto , Pressão Sanguínea , Procedimentos Cirúrgicos Cardíacos , Ecocardiografia Transesofagiana , Feminino , Insuficiência Cardíaca/etiologia , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/cirurgia , Traumatismos Cardíacos/diagnóstico , Traumatismos Cardíacos/fisiopatologia , Traumatismos Cardíacos/cirurgia , Coração Auxiliar , Hérnia/diagnóstico , Hérnia/fisiopatologia , Hérnia/terapia , Humanos , Hipotensão/diagnóstico , Hipotensão/fisiopatologia , Hipotensão/cirurgia , Miocárdio Atordoado/etiologia , Miocárdio Atordoado/fisiopatologia , Miocárdio Atordoado/cirurgia , Pericardiocentese , Resultado do Tratamento , Função Ventricular , Ferimentos Perfurantes/diagnóstico , Ferimentos Perfurantes/fisiopatologia , Ferimentos Perfurantes/cirurgiaRESUMO
With a small left ventricular aneurysm, the surgeon finds it difficult to decide whether to repair the aneurysm or leave it alone; there are risks and benefits to consider. Our choice is plication rather than resection. The procedure may be performed on-pump or off-pump, and the results are easy to demonstrate with the help of transesophageal echocardiogram.