Concomitant aortic valve repair for aortic insufficiency and implantation of left ventricle mechanical support.

BACKGROUND: Moderate to severe aortic valve insufficiency (AI) in patients undergoing left ventricular assist device (LVAD) implantation is a significant complication which occurs in up to 10.7% of patients in the INTERMACS database and has profound consequences for survival. Preoperative Impella use is associaed with greater post-LVAD AI. CASE PRESENTATION: 56 y/o Caucasian female with acute exacerbation of chronic congestive heart failure who needed urgent Impella placement followed by elective Heartmate III LVAD. CONCLUSION: Patients who have aortic valve regurgitation at the time of implantation have been handled by several methods, including aortic valve leaflets approximation, to aortic valve replacement or even valve closure. We report a case of geometric ring annuloplasty for repair of a regurgitant aortic valve during destination LVAD implantation.

A case report of superior vena cava/right coronary artery fistula secondary to chronic endocarditis.

Background: Coronary arteriovenous fistulas present an abnormal connection between the coronary arteries and an adjacent systemic or pulmonary vessel. They are rare, representing 0.002% of the general population. The majority is congenital but may additionally occur related to trauma or interventional cardiac procedures. Case summary: We present the case of a 48-year-old male with a history of untreated bacterial endocarditis developing a right coronary/superior vena cava fistula. We detail the imaging findings of this rare phenomenon to arrive at this diagnosis. We describe his clinical course and the interventions considered, including surgical extraction. Unfortunately, this patient left against medical advice before completing recommended treatment. Discussion: We present the first documentation of a right coronary/superior vena cava fistula secondary to chronic untreated bacterial endocarditis. Clinicians should be aware of this rare complication.

AngioVac Procedures: Integration of cardiac surgeon and anesthesiologist-led transesophageal echocardiography: A preliminary report.

Introduction: The AngioVac system is a novel, minimally invasive, endovascular technique used to evacuate intravascular or intracardiac vegetation or thrombus. Although most AngioVac procedures are currently performed by interventionalists, this innovative procedure has been gaining attention among the surgical and anesthesia communities. Methods: We retrospectively reviewed all patients who underwent the AngioVac procedure performed by a cardiac surgeon between August 2019 and December 2022. Fellowship-trained cardiac anesthesiologists operated TEE to navigate the AngioVac cannula during the procedure. The stored TEE images were retrospectively reviewed and independently analyzed by two cardiac anesthesiologists with specific focus on TEE-guided navigation of the AngioVac cannula towards the aspiration target. Results: Eleven patients underwent the AngioVac procedure during the study period. In nine cases, the majority of the vegetation or thrombus was successfully aspirated. In two cases, incomplete aspiration was attributed to the mass burden being too large, firm, and chronic in etiology. Worsening tricuspid regurgitation (TR) was identified in three of the 11 cases. Intraoperative TEE provided the cardiac surgeon with simultaneous display of the AngioVac cannula shaft, its tip, and aspiration target, as well as real-time assessment of TR, facilitating the minute movements essential for successful outcomes. Conclusions: This study details our experience and the effectiveness of the AngioVac system for treating soft, intracardiac vegetation or thrombus in a minimally invasive manner. Experienced cardiac anesthesiologists have the skillsets and knowledge to provide optimal live TEE imaging necessary for successful maneuvering of the AngioVac cannula.

Emergent veno-venous extracorporeal membrane oxygenation during aortic valve replacement following severe re-expansion pulmonary edema: A case report.

Re-expansion pulmonary edema is defined as pulmonary edema that occurs when a chronically collapsed lung rapidly re-expands, most commonly following chest tube placement for pneumothorax, re-expansion of severe atelectasis, and evacuation of pleural effusion. Though it is very rare, the sudden onset and clinical features of re-expansion pulmonary edema make it a lethal complication that requires urgent treatment. We present a 60-year-old patient who underwent an aortic valve replacement with pre-existing large bilateral pleural effusions. Intraoperatively, upon evacuation of the pleural effusions, the patient developed worsening lung compliance, refractory hypoxemia, and hypercapnia that required emergent veno-venous extracorporeal membrane oxygenation support.

Cardiogenic Shock in Non-Ischemic Cardiomyopathy: Dynamic Mechanical Circulatory Support and Pathophysiology Illustration.

Nonischemic cardiomyopathy (NICM) is a significant cause of cardiogenic shock (CS). We present a case of a 56-year-old previously healthy man who arrived with vague abdominal symptoms, over 2 weeks. Subsequently, the patient's condition rapidly deteriorated over 12 hours, leading to cardiogenic shock categorized as Society for Cardiovascular Angiography and Interventions (SCAI) stage D. Echocardiography and right heart catheterization confirmed multiorgan failure secondary to severe cardiac dysfunction. Mechanical circulatory support was initiated using an Impella CP device 20 hours after admission due to ongoing deterioration. Considering refractory cardiogenic shock and within 24 hours, the patient received combined veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and Impella CP support (ECPElla). With gradual improvement in the patient's clinical status and organ function, successful weaning from VA ECMO to Impella 5.5 was achieved. Ultimately, the patient underwent a successful orthotopic heart and kidney transplantation, marking a significant milestone in his recovery. The case underscores the importance of promptly identifying and responding to cardiogenic shock through invasive hemodynamic assessment. Collaborative decision-making involving a multidisciplinary team played a crucial role in the initiation, escalation, and eventual weaning of mechanical circulatory support, culminating in the successful bridging to a dual organ transplantation for this patient with CS secondary to NICM.

Transesophageal Echocardiography Assisting in the Identification of Intraabdominal Bleeding During Cardiac Surgery.

We present a case in which intraoperative transesophageal echocardiography (TEE) helped detect intraabdominal bleeding, a rare complication in cardiac surgery. A patient undergoing ascending aortic aneurysm and aortic valve repair had increasing vasopressor and transfusion requirement during sternal closure with TEE imaging revealing a nonspecific, hypoechoic fluid-like collection anterior to the stomach. Discussion between the anesthesiology and surgical teams prompted further investigation including a diagnostic laparoscopy which confirmed the presence of intraabdominal bleeding. Hemostasis was later achieved after identifying the source of bleeding from a pre-peritoneal vein and associated peritoneal defect adjacent to a mediastinal chest tube placed earlier in the operation.

Impella Support for Surgical Ventricular Septal Defect Repair.

Acute postinfarct ventricular septal defect (VSD) is associated with high mortality due to a combination of cardiogenic shock and a complex repair in recently infarcted fragile myocardium. 1 Although the Impella heart pump is established as support for cardiogenic shock, it is relatively contraindicated in postinfarct VSD because of potential right-to-left shunt or stroke due to VSD tissue-related embolus. On autopsy, early repair is technically difficult due to tissue friability and as a result, 38% of surgically repaired patients have evidence of recurrent interventricular septal rupture. 2 Delayed surgical repair (>7 days) is associated with superior survival-54% after 7 days versus 18% prior-but hemodynamic instability may prevent delay. 3 Case reports have shown successful early left ventricular unloading with Impella patients with acute postinfarct VSD before surgical repair. 4,5 We discuss our algorithm for pre-repair Impella support in which we stratify pre-repair support based on the Qp/Qs ratio. For VSD with Qp/Qs >2.5, we use a preoperative Impella heart pump and have not demonstrated reversal in the left-to-right shunt on echocardiography and/or stroke. Our findings are consistent with theoretical models of unloading as demonstrated by shifts in pressure-volume loops. 6.

Use of Sodium Bicarbonate Purge Solution in Impella Devices for Heparin-Induced Thrombocytopenia.

Heparin purge solution is recommended to be used in Impella devices to prevent biomaterial buildup and subsequent device dysfunction. The use of sodium bicarbonate purge solution in an Impella device is described in two patients with heparin-induced thrombocytopenia (HIT). The first case details a patient with severe mitral regurgitation and cardiogenic shock who had an Impella CP placed who developed HIT. Heparin purge solution was replaced by sodium bicarbonate purge solution in addition to systemic direct thrombin inhibitor (DTI) initiation. There was no significant change in Impella purge pressure or flow over the 13 days of Impella use. The second case describes a patient who developed an acute myocardial infarction and subsequent cardiogenic shock for which an Impella CP was placed who also developed HIT. Heparin purge solution was replaced by sodium bicarbonate purge solution. There was no significant change in purge pressure, flow, or motor current spikes over 11 days of use. In conclusion, we describe the successful use of a novel sodium bicarbonate purge solution utilized in patients with HIT for Impella management alone and in combination with systemic direct thrombin inhibitor therapy. This resulted in no protein deposition in the device gaps or device dysfunction.

Management of two circulations in a COVID-19 patient with secondary superinfection.

Optimal oxygenation in the intensive care unit requires adequate pulmonary gas exchange, oxygen-carrying capacity in the form of hemoglobin, sufficient delivery of oxygenated hemoglobin to the tissue, and an appropriate tissue oxygen demand. In this Case Study in Physiology, we describe a patient with COVID-19 whose pulmonary gas exchange and oxygen delivery were severely compromised by COVID-19 pneumonia requiring extracorporeal membrane oxygenation (ECMO) support. His clinical course was complicated by a secondary superinfection with staphylococcus aureus and sepsis. This case study is provided with two goals in mind (1) We outline how basic physiology was used to address life-threatening consequences of a novel infection-COVID-19. (2) We describe a strategy of whole-body cooling to lower the cardiac output and oxygen consumption, use of the shunt equation to optimize flow to the ECMO circuit, and transfusion to improve oxygen-carrying capacity when ECMO alone failed to provide sufficient oxygenation.

Acute Pulmonary Embolism Caused by Abdominal Pannus Retraction in an Awake Patient in the Operating Room: A Case Report.

We present a 67-year-old woman who was hemodynamically stable with radiographic evidence of saddle pulmonary embolism (PE) in the main pulmonary artery and mobile thrombus in the right heart. Endovascular thrombectomy was scheduled under general anesthesia. Before anesthesia induction, femoral vessel access was planned under local anesthesia in case emergent cardiopulmonary bypass (CPB) was needed. Immediately after abdominal pannus retraction was applied for better groin access, the patient developed cardiac arrest, and advanced cardiovascular life support (ACLS) protocol was initiated. Transesophageal echocardiography (TEE) confirmed acute massive PE. CPB was emergently established. Surgical embolectomy was conducted with successful outcome.

Early results of geometric ring annuloplasty for bicuspid aortic valve repair during aortic aneurysm surgery.

Objectives: Geometric ring annuloplasty has shown promise during bicuspid aortic valve repair for aortic insufficiency. This study examined early outcomes of bicuspid aortic valve repair associated with proximal aortic aneurysm replacement. Methods: From September 2017 to November, 2021, 127 patients underwent bicuspid aortic valve repair with concomitant proximal aneurysm reconstruction. Patient age was 50.6 ± 12.7 years (mean ± standard deviation), male gender was 83%, New York Heart Association Class was 2 (1-2) (median [interquartile range]), and preoperative aortic insufficiency grade was 3 (2-4). Ascending aortic diameter was 50 (46-54) mm, and all patients had ascending aortic replacement. Forty patients had sinus diameters greater than 45 mm, prompting remodeling root procedures. A total of 105 patients had Sievers type 1 valves, 3 patients had type 0, and 7 patients had type 2. A total of 118 patients had primarily right/left fusion, 8 patients had right/nonfusion, and 1 patient had left/nonfusion. Leaflet reconstruction used central leaflet plication and cleft closure, with limited ultrasonic decalcification in 31 patients. Results: Ring size was 23 (21-23) mm, and 26 of 40 root procedures were selective nonfused sinus replacements. Aortic clamp time was 139 (112-170) minutes, and bypass time was 178 (138-217) minutes. Postrepair aortic insufficiency grade was 0 (0-0) (P < .0001), and mean valve gradient was 10 (7-14) mm Hg. No early and 1 late mortality occurred. Four patients required reoperation for bleeding, and 4 patients required pacemakers. At a mean follow-up of 20 months (maximal 93), there were no valve-related complications, 5 late repair failures prompting valve replacement, and 1 death due to Coronavirus Disease 2019. Conclusions: Geometric ring annuloplasty for bicuspid aortic valve repair with proximal aortic aneurysm reconstruction is safe and associated with good early outcomes. Further experience and follow-up will help inform long-term durability.

Role of Endothelial Cells in Myocardial Ischemia-Reperfusion Injury.

Minimizing myocardial ischemia-reperfusion injury has broad clinical implications and is a critical mediator of cardiac surgical outcomes. "Ischemic injury" results from a restriction in blood supply leading to a mismatch between oxygen supply and demand of a sufficient intensity and/or duration that leads to cell necrosis, whereas ischemia-reperfusion injury occurs when blood supply is restored after a period of ischemia and is usually associated with apoptosis (i.e. programmed cell death). Compared to vascular endothelial cells, cardiac myocytes are more sensitive to ischemic injury and have received the most attention in preventing myocardial ischemia-reperfusion injury. Many comprehensive reviews exist on various aspects of myocardial ischemia-reperfusion injury. The purpose of this review is to examine the role of vascular endothelial cells in myocardial ischemia-reperfusion injury, and to stimulate further research in this exciting and clinically relevant area. Two specific areas that are addressed include: 1) data suggesting that coronary endothelial cells are critical mediators of myocardial dysfunction after ischemia-reperfusion injury; and 2) the involvement of the mitochondrial permeability transition pore in endothelial cell death as a result of an ischemia-reperfusion insult. Elucidating the cellular signaling pathway(s) that leads to endothelial cell injury and/or death in response to ischemia-reperfusion is a key component to developing clinically applicable strategies that might minimize myocardial ischemia-reperfusion injury.

Human myocardial cell lines generated with SV40 temperature-sensitive mutant tsA58.

Conditionally transformed human myocardial cell lines would be a valuable resource for studying human cardiac cell biology. We generated clonal human fetal cardiocyte cell lines by transfection of fetal ventricular cardiac cell clones with a plasmid containing a replication-defective mutant of the temperature-sensitive SV40 strain tsA58. Multiple resulting cell lines showed similar features, namely: (1) T antigen (TAg) expression at both permissive (34 degrees C) and restrictive (40.5 degrees C) temperatures; (2) extended growth capacity in comparison with parental wild type, when grown at the permissive temperature; (3) both temperature-dependent and serum-responsive growth, and; (4) an incompletely differentiated fetal phenotype which was similar at both permissive and restrictive temperatures and in the presence and absence of serum. The transformed myocyte phenotype was demonstrated using immunocytochemistry, Western and Northern blotting, and reverse transcription-polymerase chain reaction (RT-PCR). Cell lines expressed skeletal alpha-actin, atrial natriuretic peptide (ANP), and keratins, but no sarcomeric myosin heavy chain or desmin. Immunoreactive sarcomeric actin was expressed predominantly as a truncated protein of approximately 38 kD. The phenotype of the transformed cells differs from that of the wild-type parental cells as well as from those reported by others who have used TAg to immortalize rodent or human ventricular myocytes. Our cell lines should provide a useful tool for study of the molecular mechanisms regulating growth and differentiation in human cardiac muscle cells.

Successful transplantation of an older donor heart with documented myocardial bridging: a case report.

Myocardial bridging, the overlying of myocardial tissue onto epicardial coronary arteries, is an anatomic variant that is widely present in the general population. This condition can be associated with reduced forward coronary flow. Once these hearts are identified in potential donors by either visual inspection or coronary catheterization, they may no longer be considered suitable for transplantation. We present a case study that successfully utilized such a heart explanted from an older donor with "bench" myotomy repair before implantation.

Effects of nutrient and hemoglobin enriched cell free perfusates upon ex vivo isolated rat heart preparation.

We evaluated the effects of nutrient enriched medium and hemoglobin based oxygen carrier (HBOC) upon myocardial functional recovery after 15 minutes of warm ischemia in an isovolumic Langendorff rat heart model. Hearts (n = 8/group) were perfused at constant pressure (90 mm Hg) with Krebs-Henseleit buffer or HEPES modified cell culture medium (M199) in the absence and presence of HBOC. Hearts received 15 minutes of normothermic no flow ischemia followed by 60 minutes reperfusion. Hemodynamics, coronary flow, and tissue water content were measured, and microscopic evidence of injury including TUNEL assay was assessed. Preischemic left ventricular performance (left ventricular developed pressure and maximum rate of positive and negative change in systolic pressure) and coronary flow were similar among groups. At 60 minutes of reperfusion, M199 alone provided more stable and complete left ventricular systolic and diastolic functional recovery than any other perfusate. Coronary flow rates reflected left ventricular function observed under each perfusate condition. TUNEL assay showed arterial endothelial cell death in some hearts perfused with HBOC. Tissue water content did not reflect functional recovery. The combination of M199 and HBOC was associated with poor recovery and elevated perfusate methemoglobin. In this system, postischemic dysfunction is prevented by components in M199. Added HBOC does not improve functional recovery and negates the salutary effects of M199, possibly by augmenting methemoglobin formation.

Off-pump technique for Thoratec left ventricular assist device insertion.

We present a case of left ventricular assist device (Thoratec; Thoratec Laboratories Corp, Pleasanton, CA) insertion performed through a left thoracotomy without cardiopulmonary bypass in a patient with severe end-stage congestive heart failure with renal and respiratory dysfunction and a history of multiple cardiac operations.

Induction of alloreactive cytotoxic T lymphocytes by intra-splenic immunization with allogeneic class I Major Histocompatibility Complex DNA and DC-chol cationic liposomes.

A simple strategy for designing a cancer immunotherapeutic system involves modification of tumor cells from tumor-bearing animals in vivo in such a way that the host can evoke a specific immune response against them. We have expressed allogeneic class I major histocompatibility complex (MHC) molecules on tumor cells, through ex vivo DNA-mediated gene transfer. These molecules are potent immuno-modulators for the stimulation of strong immune reactions against certain malignancies. In order to achieve efficient gene delivery to tumor cells in vivo we have compared the efficiencies of gene transfer into mammalian tumor cells by the biolistic particle delivery system and cationic liposomes. In this report, we have demonstrated that cationic liposomes prepared by DC-chol and DOPE gives the best efficiency of transfection for tumor cells in vivo. We also showed that a strong anti-H-2Kb allo-reactive cytotoxic T lymphocyte (CTL) response could be generated following in vivo immunization of AKR/J mouse spleens with the H-2Kb gene and DC-chol cationic liposomes. The direct immunization of mouse spleens to induce cell-mediated immunity against exogenous antigens may allow alternative treatment strategies for cancer immunotherapy.