Successful Management of Thrombosis of the Proximal Aorta after Implantation with a Biventricular Assist Device.

Continuous-flow ventricular assist devices (CVADs) are associated with a significant complication profile that includes thrombosis of the ascending aorta and aortic valve, thromboembolism, and stroke. Despite an increasing number of reports of thromboembolic complications related to CVADs, there is little in the literature to guide their management. This report describes successful management strategies used during two cases of thrombosis of the ascending aorta during biventricular CentriMag (Levitronix LLC, Waltham, MA) support, including using pre-existing cannulas to initiate cardiopulmonary bypass.

Bibliometric Analysis of the Top 100 Most Cited Articles in the First 50 Years of Heart Transplantation.

The world celebrates over 50 years since the first human-to-human heart transplant. Bibliometric analysis is a statistical concept that has recently evolved, enabling scientists to study citation patterns and identify characteristics of highly cited scholarly work in different fields. Although it has been widely utilized, such analyses have not been conducted to date on heart transplant literature. We sought to assess the characteristics of the top 100 most referenced citations in the field of heart transplantation. We searched the Scopus database (www.scopus.com) to identify all articles relating to heart transplantation. The articles were arranged in descending order from most cited to least cited and selected articles were scrutinized for data extraction. One hundred articles were included in the final list. Of the total 40,660 citations identified, 3,210 (8.0%) were self-citations, which impacted the final rank order. The articles were published in 25 different journals between 1960 and 2013. The most productive 5-year time period was between 2000 and 2005, when 24 of the 100 most cited publications were produced. There was no correlation between the journals' impact factors and the number of articles produced per journal. The presence and type of funding were not associated with the number of citations. Over 85% of first and senior investigators were men. In conclusion, our study highlights key features of the most highly cited scientific literature on heart transplantation and provides insights into trends of published work in this field. Additionally, this work may serve as a useful guide to researchers and funding bodies by highlighting the most prolific areas of cardiac transplant research to date.

A decade of short-term outcomes in post cardiac surgery ventricular assist device implantation: data from the Society of Thoracic Surgeons' National Cardiac Database.

BACKGROUND: Previous studies showed 75% mortality before hospital discharge in patients with a ventricular assist device (VAD) placed for post-cardiac surgery shock. We examined a large national clinical database to assess trends in the incidence of post-cardiac surgery shock requiring VAD implantation, survival rates, and risk factors for mortality. METHODS AND RESULTS: We identified patients undergoing a VAD procedure after cardiac surgery at US hospitals participating in the Society of Thoracic Surgeons' National Cardiac Database during the years 1995 to 2004. Baseline characteristics and operative outcomes were analyzed in 2.5-year increments. Logistic regression modeling was performed to provide risk-adjusted operative mortality and morbidity odds ratios. A total of 5735 patients had a VAD placed during the 10-year period (0.3% cardiac surgeries). Overall survival rate to discharge after VAD placement was 54.1%. With the earliest period (January 1995 through June 1997) used as reference, the mortality odds ratio declined to 0.72 (July 1997 through December 1999) and eventually to 0.41 (July 2002 through December 2004; P<0.0001). The combined mortality/morbidity odds ratio also declined, to 0.84 and 0.48 over identical periods (P<0.0001). Preoperative characteristics associated with increased mortality were urgency of procedure, reoperation, renal failure, myocardial infarction, aortic stenosis, female sex, race, peripheral vascular disease, New York Heart Association class IV, cardiogenic shock, left main coronary stenosis, and valve procedure (c index=0.755). CONCLUSIONS: After adjustment for clinical characteristics of patients requiring mechanical circulatory support, rates of survival to hospital discharge have improved dramatically. Insertion of a VAD for post-cardiac surgery shock is an important therapeutic intervention that can salvage most of these patients.

Lessons learned from the first fully magnetically levitated centrifugal LVAD trial in the United States: the DuraHeart trial.

BACKGROUND: The DuraHeart is a continuous centrifugal-flow left ventricular assist device that uses active magnetic levitation for impeller positioning designed for improved hemocompatibility and durability. This study reviews the results of the US trial with specific attention to hemolysis, thrombotic complications, and pump failure. METHODS: The US SUSTAIN trial was a multicenter, prospective, single-arm observational study in advanced heart failure patients listed for transplantation. Follow-up was complete in 100% of the patients at 6 months. RESULTS: Sixty-three patients were enrolled at 23 centers. Forty-six patients (73%) reached the primary end points of survival to transplantation, alive on the original device at 180 days and listed for transplantation, or explant for recovery. Median duration of support was 267 days (range, 10 to 952 days) with a total support time of 46 patient-years. There was no clinical hemolysis reported during the study. Mean lactate dehydrogenase values peaked at day 4 and significantly decreased during support (435±236 U/L and 297±142 U/L on day 3 and day 180, respectively). There were no cases of pump thrombosis reported, and 3 cases of pump thrombus "in transit" (0.06 events/patient-year) were observed. There were 6 (10%) cases of magnetic levitation system failure, all secondary to cable wire fractures (0.12 events/patient-year). All patients were hemodynamically stable with the backup hydrodynamic mode. Major adverse events included gastrointestinal bleeding (0.52 events/patient-year), ischemic and hemorrhagic strokes (0.17 events/patient-year and 0.09 events/patient-year, respectively), and driveline infections (0.67 events/patient-year). CONCLUSIONS: The DuraHeart demonstrated good hemocompatibility; however, the reliability of full magnetic levitation systems should be a high priority in future pump designs.

Infection after implantation of pulsatile mechanical circulatory support devices.

OBJECTIVE: INTERMACS is a registry of mechanical circulatory support devices sponsored by the National Institutes of Health. This analysis uses INTERMACS data to define the time course, incidence, and outcome of infection adverse events focusing on the first 3 months after implant. METHODS: Patients entered into INTERMACS from June 23, 2006, to September 30, 2008, were analyzed. Preimplant data (demographics, hemodynamics, and laboratory values), infection adverse events, and other outcomes were recorded. Infection adverse events were analyzed to compare infection rates in subgroups of patients and define risk factors for death. RESULTS: The analysis was confined to pulsatile mechanical circulatory support devices. A total of 593 patients from 88 institutions were entered. Infection was a relatively common event within the first 3 months of implant and was significantly (P = .005) more common in patients with biventricular assist devices than in patients with left ventricular assist devices, although the prevalence of infection equalized in months 4 to 12. Infection had a significant adverse effect on survival. Independent risk factors for death included support with a biventricular assist device, older age, severity of patient illness implantation of the device (INTERMACS level 1), and higher blood urea nitrogen. CONCLUSIONS: Infection remains a relatively frequent adverse event and is associated with decreased survival. Interventions to prevent infection that focus on the preoperative and immediate postoperative periods are the ones most likely to achieve success by diminishing the incidence of infection during the initial 3 months after implantation. Rotary (continuous-flow) pumps are expected to have lower infection rates, but this remains to be seen.

Clinical management of continuous-flow left ventricular assist devices in advanced heart failure.

Continuous-flow left ventricular assist devices (LVAD) have emerged as the standard of care for advanced heart failure patients requiring long-term mechanical circulatory support. Evidence-based clinical management of LVAD-supported patients is becoming increasingly important for optimizing outcomes. In this state-of-art review, we propose key elements in managing patients supported with the new continuous-flow LVADs. Although most of the presented information is largely based on investigator experience during the 1,300-patient HeartMate II clinical trial, many of the discussed principles can be applied to other emerging devices as well. Patient selection, pre-operative preparation, and the timing of LVAD implant are some of the most important elements critical to successful circulatory support and are principles universal to all devices. In addition, proper nutrition management and avoidance of infectious complications can significantly affect morbidity and mortality during LVAD support. Optimizing intraoperative and peri-operative care, and the monitoring and treatment of other organ system dysfunction as it relates to LVAD support, are discussed. A multidisciplinary heart failure team must be organized and charged with providing comprehensive care from initial referral until support is terminated. Preparing for hospital discharge requires detailed education for the patient and family or friends, with provisions for emergencies and routine care. Implantation techniques, troubleshooting device problems, and algorithms for outpatient management, including the diagnosis and treatment of related problems associated with the HeartMate II, are discussed as an example of a specific continuous-flow LVAD. Ongoing trials with other continuous-flow devices may produce additional information in the future for improving clinical management of patients with these devices.

Surviving severe acute respiratory distress syndrome: utility of open-lung biopsy and large doses of dexamethasone.

The etiology of acute respiratory distress syndrome is wide and mortality is extremely high. We describe a patient dying from severe acute respiratory distress syndrome who had a tremendous recovery after receiving dexamethasone (1 g daily). This patient required positive end-expiratory pressure (up to 18 mm/Hg) and fractional inspiratory oxygen (up to 100%). Thirty-six hours after the large dose of corticosteroids, the respiratory mechanics and oxygenation were acceptable for extubation. Acute respiratory distress syndrome was proven and other etiologies of respiratory failure were ruled out by a bedside open-lung biopsy. The biopsy proven acute respiratory distress syndrome dramatically resolved with this salvage therapy. High-dose usage of corticosteroids for acute respiratory distress syndrome has tremendous potential.