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AIM: The RESHAPE-HF2 trial is designed to assess the efficacy and safety of the MitraClip device system for the treatment of clinically important functional mitral regurgitation (FMR) in patients with heart failure (HF). This report describes the baseline characteristics of patients enrolled in the RESHAPE-HF2 trial compared to those enrolled in the COAPT and MITRA-FR trials. METHODS AND RESULTS: The RESHAPE-HF2 study is an investigator-initiated, prospective, randomized, multicentre trial including patients with symptomatic HF, a left ventricular ejection fraction (LVEF) between 20% and 50% with moderate-to-severe or severe FMR, for whom isolated mitral valve surgery was not recommended. Patients were randomized 1:1 to a strategy of delivering or withholding MitraClip. Of 506 patients randomized, the mean age of the patients was 70 ± 10 years, and 99 of them (20%) were women. The median EuroSCORE II was 5.3 (2.8-9.0) and median plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) was 2745 (1407-5385) pg/ml. Most patients were prescribed beta-blockers (96%), diuretics (96%), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors (82%) and mineralocorticoid receptor antagonists (82%). The use of sodium-glucose cotransporter 2 inhibitors was rare (7%). Cardiac resynchronization therapy (CRT) devices had been previously implanted in 29% of patients. Mean LVEF, left ventricular end-diastolic volume and effective regurgitant orifice area (EROA) were 31 ± 8%, 211 ± 76 ml and 0.25 ± 0.08 cm2, respectively, whereas 44% of patients had mitral regurgitation severity of grade 4+. Compared to patients enrolled in COAPT and MITRA-FR, those enrolled in RESHAPE-HF2 were less likely to have mitral regurgitation grade 4+ and, on average, HAD lower EROA, and plasma NT-proBNP and higher estimated glomerular filtration rate, but otherwise had similar age, comorbidities, CRT therapy and LVEF. CONCLUSION: Patients enrolled in RESHAPE-HF2 represent a third distinct population where MitraClip was tested in, that is one mainly comprising of patients with moderate-to-severe FMR instead of only severe FMR, as enrolled in the COAPT and MITRA-FR trials. The results of RESHAPE-HF2 will provide crucial insights regarding broader application of the transcatheter edge-to-edge repair procedure in clinical practice.
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Data regarding rotational atherectomy percutaneous coronary intervention (RA PCI) angioplasty in the left main (LM) coronary artery are scarce, and mostly outdated. We aimed to describe clinical outcomes of RA PCI in LM. Patients requiring RA in 8 European countries and 19 centers were prospectively and consecutively included in the European registry of Cardiac Care of Calcified and Complex patients registry. In-hospital data collection and 1-year follow-up were performed for each patient. Between October 2016 and July 2018, 966 patients with complete data were included. Among them, 241 presented with an LM lesion, and 171 required an LM lesion preparation by RA. The latter, allocated to the LM-RA group, were compared with the 725 patients in the non-LM-RA group. Clinical success of the RA procedure was comparable in both groups, but in-hospital major adverse cardiac events were higher in the RA-LM group (7.6% vs 3.2%, adjusted p = 0.04), mainly driven by a higher in-hospital mortality rate (5.3 vs 0.3%, adjusted p = 0.005). At 1-year follow-up, mortality and major adverse cardiac event rates were comparable in both groups (12.9% vs 8.0%, adjusted p value: 0.821, and 15.8% vs 10.9%, adjusted p value: 0.329, respectively), but the rate of target vessel revascularization remained higher in the RA-LM group (5.3% vs 3.2%, adjusted p = 0.021). In conclusion, RA PCI is an efficient option for calcified LM lesions, providing acceptable outcomes regarding this population with high risk at 1 year, and yields comparable outcomes with RA PCI performed on non-LM lesions.
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Aterectomía Coronaria , Enfermedad de la Arteria Coronaria , Intervención Coronaria Percutánea , Calcificación Vascular , Humanos , Aterectomía Coronaria/métodos , Intervención Coronaria Percutánea/métodos , Resultado del Tratamiento , Angiografía Coronaria/métodos , Calcificación Vascular/cirugíaAsunto(s)
COVID-19 , Cardiología , Ablación por Catéter , COVID-19/epidemiología , Grecia/epidemiología , Humanos , Pandemias , Sistema de RegistrosRESUMEN
The identification of patients prone to atrial fibrillation (AF) relapse after catheter ablation is essential for better patient selection and risk stratification. The current prospective cohort study aims to validate a novel P-wave index based on beat-to-beat (B2B) P-wave morphological and wavelet analysis designed to detect patients with low burden AF as a predictor of AF recurrence within a year after successful catheter ablation. From a total of 138 consecutive patients scheduled for AF ablation, 12-lead ECG and 10 min vectorcardiogram (VCG) recordings were obtained. Univariate analysis revealed that patients with higher B2B P-wave index had a two-fold risk for AF recurrence (HR: 2.35, 95% CI: 1.24-4.44, p: 0.010), along with prolonged P-wave, interatrial block, early AF recurrence, female gender, heart failure history, previous stroke, and CHA2DS2-VASc score. Multivariate analysis of assessable predictors before ablation revealed that B2B P-wave index, along with heart failure history and a history of previous stroke or transient ischemic attack, are independent predicting factors of atrial fibrillation recurrence. Further studies are needed to assess the predictive value of the B2B index with greater accuracy and evaluate a possible relationship with atrial substrate analysis.
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Data regarding the potential influence of gender on outcomes of rotational atherectomy (RA) percutaneous coronary intervention (PCI) are scarce and conflicting. Using the Euro4C registry, an international prospective multicentric registry of RA PCI, we evaluated the influence of gender on clinical outcomes of RA PCI. Between October 2016 and July 2018, 966 patients were included. In them, 267 (27.6%) were females. Female patients were older than males (77.7 years old ± 9.8 vs 73.3 ± 9.5 years old respectively, p < 0.001) had a poorer renal function (43,1% of females had a GFR < 60 ml/min:1.73m² vs 30.4% of males, p < 0.001) and were more frequently admitted for an acute coronary syndrome (32.2% vs 22.3% pâ¯=â¯0.002). During RA procedure, women were less likely to be treated by radial approach (65.0% vs 74.4%, pâ¯=â¯0.004). In-hospital major adverse cardiac event rate-defined as cardiovascular death, myocardial infarction, stroke/transient ischemic attack, target lesion revascularization, and coronary artery bypass grafting surgery-was higher in the female group (7.1% vs 3.7%, pâ¯=â¯0.043). However, coronary perforation, dissection, slow/low flow and tamponade did not significantly differ in gender, neither did cardiovascular medications at discharge. At 1 year follow-up, rate of major adverse cardiac event was 18.4% in the female group vs 11.2% in the male group (adjusted Hazard Ratio 1.82 [1.24 to 2.67], pâ¯=â¯0.002). No significant bleeding differences were observed in gender, neither in hospital, nor during follow-up. In conclusion women had worse clinical outcomes following RA PCI during hospitalization and at 1 year follow-up than did men.
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Síndrome Coronario Agudo/epidemiología , Aterectomía Coronaria/métodos , Enfermedad de la Arteria Coronaria/cirugía , Calcificación Vascular/cirugía , Distribución por Edad , Anciano , Anciano de 80 o más Años , Taponamiento Cardíaco/epidemiología , Enfermedades Cardiovasculares/mortalidad , Puente de Arteria Coronaria/estadística & datos numéricos , Enfermedad de la Arteria Coronaria/epidemiología , Europa (Continente)/epidemiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Infarto del Miocardio/epidemiología , Intervención Coronaria Percutánea/métodos , Complicaciones Posoperatorias/epidemiología , Arteria Radial , Sistema de Registros , Insuficiencia Renal/epidemiología , Factores Sexuales , Accidente Cerebrovascular/epidemiología , Resultado del Tratamiento , Calcificación Vascular/epidemiología , Lesiones del Sistema Vascular/epidemiologíaRESUMEN
We present a case of an 84-year old patient with severe mitral and tricuspid regurgitation with a lot of cormobidities who underwent a simultaneous transfemoral (one approach) mitral and tricuspid valve repair using the MitraClip system.
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Implantación de Prótesis de Válvulas Cardíacas/instrumentación , Implantación de Prótesis de Válvulas Cardíacas/métodos , Prótesis Valvulares Cardíacas , Insuficiencia de la Válvula Mitral/cirugía , Válvula Mitral/cirugía , Insuficiencia de la Válvula Tricúspide/cirugía , Válvula Tricúspide/diagnóstico por imagen , Anciano de 80 o más Años , Cateterismo Cardíaco , Ecocardiografía , Diseño de Equipo , Humanos , Masculino , Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/complicaciones , Insuficiencia de la Válvula Mitral/diagnóstico , Válvula Tricúspide/cirugía , Insuficiencia de la Válvula Tricúspide/complicaciones , Insuficiencia de la Válvula Tricúspide/diagnósticoRESUMEN
OBJECTIVE: We examined trans-radial approach (TRA) use in coronary angiographies (CAs) as well as in percutaneous coronary interventions (PCIs) in specific regions of Greece, its distribution in public and private catheterization laboratories (CLs) and its preference by operators. Reliable data regarding the use of TRA are not available in Greece. METHODS: The study was performed in northern and central Greece, which constitutes 35.32% of the national population. This study focused on the years 2004, 2009 and 2013. RESULTS: There are 12 CLs. CAs performed using TRA were 0.43% in 2004, 12.28% in 2009 and 39.81% in 2013, whereas PCIs performed using TRA were 0.38%, 9.20% and 39.48%, respectively. Operators familiar with TRA, but who performed TRA electively, were 13.33% in 2004, 60.38% in 2009 and 42.37% in 2013. However, operators performing TRA routinely were 2.2%, 5.66%, and 49.15%, respectively. In 2013, there was a 3.76% decrease in CAs and 4.51% decrease in PCIs compared to 2009; in private CLs, there was a 29.63% decrease in CAs and 34.72% decrease in PCIs performed, which was contradictory to the 27.27% increase observed in CAs and 29.83% increase in PCIs in public CLs. CONCLUSIONS: This is the first study to reveal the volumes and trends in interventions performed via TRA across central and northern Greece. TRA has gained a reputation among operators in both public and private CLs. Due to the financial crisis in Greece, catheterizations have been diminished, whereas private CLs have lost a great amount of their turnover.
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Angiografía Coronaria/métodos , Intervención Coronaria Percutánea/métodos , Arteria Radial/cirugía , Angiografía Coronaria/estadística & datos numéricos , Femenino , Grecia , Humanos , Masculino , Intervención Coronaria Percutánea/estadística & datos numéricos , Sistema de Registros , Resultado del TratamientoAsunto(s)
Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Prótesis Valvulares Cardíacas/efectos adversos , Complicaciones Posoperatorias , Falla de Prótesis/etiología , Reoperación/métodos , Anciano , Ecocardiografía Tridimensional/métodos , Femenino , Fluoroscopía/métodos , Implantación de Prótesis de Válvulas Cardíacas/métodos , Humanos , Complicaciones Posoperatorias/diagnóstico por imagen , Resultado del TratamientoRESUMEN
INTRODUCTION: Surgical septal myectomy is thought to be the gold standard of treatment for obstructive hypertrophic cardiomyopathy (HCM) with obstruction symptoms refractory to optimal medical therapy. In Europe, during the last 2 decades, myectomy has been set aside, while alcohol septal ablation has been widely promoted. In this paper, we analyze our first experience of surgical septal myectomy in a small cohort of patients with HCM coming from a single tertiary center. METHODS: Thirty-two patients (16 male, 50%) with a mean age of 58.1 ± 14.4 (range 12-79 years) underwent myectomy for HCM symptoms refractory to negative inotropic agents. The technique used for the myectomy was the one introduced by Andrew Morrow. Mean follow-up time after procedure was 16.8 ± 13.3 months with a median of 13 months (range 4-58 months). RESULTS: Post-myectomy, there was a significant improvement in patients' NYHA class (from 3.3 ± 0.46 to 1.38 ± 0.49, p<0.0005), while interventricular septum thickness was reduced from 2.3 ± 0.4 cm to 1.6 ± 0.4 cm (p<0.0005), and peak gradient at the site of obstruction from 94.9 ± 29 to 16.7 ± 7.9 mmHg (p<0.0005). During the follow-up period, only 1 out of 32 patients died, from non-cardiovascular causes, with the overall survival post-myectomy being 97.2% (95%CI: 94.5-99.9%) at 1-year follow up. CONCLUSIONS: Surgical septal myectomy in patients with HCM and drug-refractory symptoms is a safe procedure that greatly improves symptoms and quality of life. Further follow-up of our patients is mandatory in order to determine whether the good survival rate achieved at 1 year will persist.
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Procedimientos Quirúrgicos Cardíacos , Cardiomiopatía Hipertrófica , Tabiques Cardíacos , Obstrucción del Flujo Ventricular Externo , Adulto , Anciano , Procedimientos Quirúrgicos Cardíacos/métodos , Procedimientos Quirúrgicos Cardíacos/mortalidad , Procedimientos Quirúrgicos Cardíacos/psicología , Cardiomiopatía Hipertrófica/complicaciones , Cardiomiopatía Hipertrófica/fisiopatología , Cardiomiopatía Hipertrófica/cirugía , Fármacos Cardiovasculares/uso terapéutico , Resistencia a Medicamentos , Ecocardiografía Doppler/métodos , Femenino , Estudios de Seguimiento , Grecia , Tabiques Cardíacos/diagnóstico por imagen , Tabiques Cardíacos/cirugía , Humanos , Masculino , Persona de Mediana Edad , Periodo Posoperatorio , Calidad de Vida , Recuperación de la Función , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Análisis de Supervivencia , Resultado del Tratamiento , Obstrucción del Flujo Ventricular Externo/etiología , Obstrucción del Flujo Ventricular Externo/fisiopatología , Obstrucción del Flujo Ventricular Externo/cirugíaRESUMEN
INTRODUCTION: The treatment of calcified coronary artery lesions is a challenge for percutaneous angioplasty. Rotational atherectomy is an established technique for the effective modification of these lesions prior to conventional angioplasty and stent implantation. Drug-eluting stents (DES) have shown encouraging results in complex lesions and high-risk patients. METHODS: This retrospective study investigated the immediate and long-term prognosis after treatment with rotational atherectomy (RotA) and DES implantation in 184 patients with calcified coronary artery lesions. RESULTS: During follow up (mean 49 months), 7 patients died (1 from a non-cardiac cause) and the incidence of major adverse cardiac events was 14.85%. Only 4.15% of patients underwent a new angioplasty procedure. CONCLUSIONS: The combination of RotA and DES in calcified coronary artery lesions has a very good angiographic result and a satisfactory clinical outcome.
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Aterectomía Coronaria , Enfermedad de la Arteria Coronaria/terapia , Stents Liberadores de Fármacos , Calcificación Vascular/terapia , Anciano , Terapia Combinada , Femenino , Humanos , Masculino , Estudios Retrospectivos , Índice de Severidad de la EnfermedadRESUMEN
INTRODUCTION: The incidence of percutaneous closure of secundum atrial septal defects (ASD) and patent foramen ovale (PFO), which has become an established therapy, is constantly increasing. In this study, which is the first in the Greek literature, we present the immediate and mid-term results from this intervention in our center. METHODS: From April 2004 to April 2008, 103 patients underwent percutaneous closure of an ASD or PFO using Amplatzer closure devices. Thirty were male, the mean age was 37 +/- 15.5 years, and the mean follow-up period 21.7 +/- 14.8 months. The procedure was successful in 102 of the above patients; 69 (mean age 36.3 years +/- 17.1, 81% female) underwent secundum ASD closure, while 33 patients (mean age 39.1 +/- 10.5 years, 16 female and 17 male) underwent percutaneous closure of a PFO due to cryptogenic stroke. RESULTS: There were no major complications during the procedure (death, device embolization or need for immediate cardiac surgery). There were minor complications in 8 (7.7%) patients (bleeding at the puncture site, transient ST elevation in the inferior leads, multiple atrial and ventricular ectopics). The transient ST elevation in the inferior leads appeared in 5 patients (5%) and was probably due to air embolization. This transient complication completely resolved within 3 minutes. During the follow-up period, no patient had a major complication (cardiac rupture, device embolization, thrombus formation, thromboembolism or infective endocarditis). Most importantly, in the patients who underwent PFO closure there were no recurrences of cryptogenic stroke during the follow-up period (24.3 +/- 14.5 months). CONCLUSIONS: This study shows that using Amplatzer closure devices for atrial septal communications is both safe and effective, with sustained results over a maximum follow-up period of four years. Appropriate patient selection, as well as accurate device sizing fitting the dimensions of the defect, are important factors for the success and the safety of the method.
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Foramen Oval Permeable/cirugía , Defectos del Tabique Interatrial/cirugía , Complicaciones Posoperatorias/prevención & control , Dispositivo Oclusor Septal , Adulto , Ecocardiografía Transesofágica , Femenino , Estudios de Seguimiento , Foramen Oval Permeable/diagnóstico por imagen , Grecia , Defectos del Tabique Interatrial/diagnóstico por imagen , Humanos , Incidencia , Masculino , Diseño de Prótesis , Factores de Tiempo , Resultado del TratamientoAsunto(s)
Insuficiencia de la Válvula Aórtica/cirugía , Válvula Aórtica/cirugía , Bioprótesis , Implantación de Prótesis de Válvulas Cardíacas/métodos , Prótesis Valvulares Cardíacas , Anciano de 80 o más Años , Válvula Aórtica/diagnóstico por imagen , Insuficiencia de la Válvula Aórtica/diagnóstico por imagen , Cateterismo Cardíaco , Ecocardiografía Transesofágica , Humanos , Masculino , Procedimientos Quirúrgicos Mínimamente Invasivos , Falla de Prótesis , ReoperaciónRESUMEN
BACKGROUND: The aim of this study is to evaluate a percutaneous left ventricular assist device (Tandem Heart pVAD; Cardiac Assist, Pittsburgh, Pennsylvania) in the postcardiotomy setting. METHODS: Between August 2001 and August 2004, 11 high-risk male patients who had undergone heart failure surgery or surgical revascularization were supported by the TandemHeart postcardiotomy. The major indication for pVAD insertion was failure to wean from cardiopulmonary bypass. Three different techniques were employed for cannulation: the closed percutaneous technique, the "open transeptal" technique with percutaneous cannulas insertion, and direct central cannulation. RESULTS: The mean duration of support was 88 hours. The mean pump flow was 3.09 L/min. The weaning rate was 72.72%. Survival to discharge and at 1 and 4 years was 54.54%, 45.45%, and 36.36%, respectively. The main complication was pericardial bleeding, noted mainly in patients receiving antiplatelet treatment preoperatively. CONCLUSIONS: The TandemHeart appears to be safe for temporary support after cardiotomy. It is a versatile device allowing different techniques of insertion. Device application yielded high weaning rate and satisfactory early and long-term survival.
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Procedimientos Quirúrgicos Cardíacos , Corazón Auxiliar , Anciano , Anciano de 80 o más Años , Cateterismo Cardíaco , Gasto Cardíaco , Causas de Muerte , Oxigenación por Membrana Extracorpórea , Insuficiencia Cardíaca/mortalidad , Insuficiencia Cardíaca/cirugía , Corazón Auxiliar/efectos adversos , Humanos , Contrapulsador Intraaórtico , Masculino , Persona de Mediana Edad , Estudios RetrospectivosAsunto(s)
Cardiomiopatía Hipertrófica/cirugía , Factores de Edad , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/métodos , Ablación por Catéter/métodos , Muerte Súbita Cardíaca/etiología , Etanol/uso terapéutico , Tabiques Cardíacos/cirugía , Ventrículos Cardíacos/cirugía , Humanos , Imagen por Resonancia Cinemagnética , MiocardioRESUMEN
Dilatation of the pulmonary autograft after the Ross procedure is a possible complication, necessitating aortic valve replacement. We present a case of a patient who developed pulmonary autograft dilatation and was treated successfully with valve-sparing aortic root reimplantation with a Valsalva graft.
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Aneurisma/cirugía , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Procedimientos Quirúrgicos Cardíacos/métodos , Válvula Pulmonar/trasplante , Adolescente , Aneurisma/etiología , Estenosis de la Válvula Aórtica/cirugía , Dilatación Patológica , Humanos , Masculino , Válvula Pulmonar/patología , Reimplantación , Trasplante AutólogoRESUMEN
INTRODUCTION: The Ross procedure is a safe alternative option for aortic valve replacement in selected patients. Here we present the medium-term results of our experience with this procedure. METHODS: Between December 1998 and January 2004, 21 patients (16 male, 5 female, mean age 42 years) underwent aortic valve replacement using the Ross operation. Indications for operation were aortic stenosis in 5 patients, aortic regurgitation in 5 patients, aortic stenosis and regurgitation in 9 patients, acute septic endocarditis of a native aortic valve in 1 patient and of a mechanical aortic valve in 1 patient. The root replacement technique was used in 17 patients (81%) and the subcoronary insertion technique in 4 patients (19%). RESULTS: Hospital mortality was 4.7% (1 patient) and late mortality is zero. Mean follow up duration was 4 years (range 1-6 years). On follow up all of the patients were in New York Heart Association class I. One patient developed neo-aortic root dilatation (5.1 cm) with mild neo-aortic valve regurgitation and underwent a modified David I procedure using a Valsalva graft. None of the patients had a gradient of more than 10 mmHg through the pulmonary autograft. Sixteen patients had no aortic insufficiency, while mild aortic regurgitation developed in three patients. Pulmonary valve regurgitation developed in 11 patients (range 8-75 mmHg) but only one patient (75 mmHg) developed significant asymptomatic stenosis. CONCLUSIONS: Our experience with the Ross procedure suggests that aortic root replacement with a pulmonary autograft can be performed safely in adult patients. Pulmonary homograft degeneration requiring reintervention might be a rare complication.
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Válvula Aórtica/trasplante , Enfermedades de las Válvulas Cardíacas/cirugía , Válvula Pulmonar/trasplante , Adolescente , Adulto , Femenino , Estudios de Seguimiento , Enfermedades de las Válvulas Cardíacas/mortalidad , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Trasplante Autólogo , Trasplante Homólogo , Resultado del TratamientoRESUMEN
Surgical treatment of heart failure is emerging as one of the most challenging clinical dilemmas for patients with end-stage cardiac failure not amenable to medical treatment. One of the most intriguing techniques is the use of implantable left ventricular assist devices (LVADs) as a bridge to recovery. The early experience from our centre has shown that even short term post-cardiotomy mechanical assistance, after heart failure surgery, improves patient outcome; thus, a clinical feasibility study was designed. The hypothesis of the study is that reparative heart failure surgery combined with postoperative mechanical support, ventricular resynchronisation where indicated, and pharmacological treatment can maximise myocardial recovery. In the study a new, implantable, magnetically levitated, rotary pump will be used as a bridge to recovery. In this manuscript the first worldwide human implantation of a new, continuous-flow LVAD, the WorldHeart Rotary Pump (Levacor, WorldHeart Inc., Oakland CA), is reported. The design and the rationale of the feasibility study, the inclusion and exclusion criteria, and the primary and secondary end points of the clinical investigation, are delineated. In addition, the design of the new rotary pump, its general principles of operation, and the implantation technique are described.
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Procedimientos Quirúrgicos Cardíacos/instrumentación , Procedimientos Quirúrgicos Cardíacos/métodos , Corazón Auxiliar , Diseño de Equipo , Estudios de Factibilidad , Insuficiencia Cardíaca/cirugía , Humanos , Estudios Prospectivos , Reproducibilidad de los Resultados , Disfunción Ventricular Izquierda/cirugíaRESUMEN
Postcardiotomy left ventricular failure (LVF) complicating a cardiac surgical procedure is usually managed with intraaortic balloon pump (IABP) counterpulsation. We report two cases of postcardiotomy LVF unresponsive to inotropic support and IABP counterpulsation that were managed successfully with the use of the TandemHeart percutaneous ventricular assist device (pVAD) (CardiacAssist, Pittsburgh, PA). The TandemHeart pVAD appears to be safe and effective as a bridge to recovery in the treatment of postcardiotomy cardiac failure.