Thromboembolic complications following implantation of durable left-ventricular assist devices.

INTRODUCTION: As the utilization of left-ventricular assist devices (LVADs) continues to rise and patients experience extended survival duration with these devices, the overall incidence of adverse events and complications has shown a notable increase. Among the major adverse events, thromboembolic complications are particularly significant. The aim of this study is to present our experience and assess the risk of thromboembolic complications after implantation of durable continuous-flow left-ventricular assist devices (CF-LVAD) in patients with end-stage heart failure. PATIENTS AND METHODS: From 2007 to 2022, 169 left ventricular continuous-flow durable mechanical assist devices were implanted at our institute. Three types of devices were employed: HeartMate II (n = 54, 32%), HeartMate 3 (n = 70, 41.4%), and Heart Ware (n = 45, 26.6%). The data were extracted from the EUROMACS register. RESULTS: Thromboembolic complication, pump thrombosis was observed in 11/169 patients (6.5%), with 2 patients experiencing stroke after embolism to the central nervous system. Among these cases, 10 patients (90.9%) were equipped with the Heart Ware device while 1 patient (9.1%) had the Heart Mate II device implanted. Nine patients received the durable device as a bridge to transplant therapy and two as a bridge to candidacy. The overall mean age of the patients was 47.6±10.2 years, with 2 women and 10 men. The pump thrombosis was managed through thrombolytic therapy, high-intensity heparin anticoagulation protocol, pump exchange, pump explantation, and early heart transplant. The combined hospital and long-term mortality rate was 4/11 patients (36.4%). CONCLUSION: Based on our experience, thromboembolic complications presenting primarily as pump thromboses, were a relatively common phenomenon experienced in association with the second-generation continuous-flow devices, but rarely seen with the third-generation devices. Thrombolysis followed by early heart transplantation proved to be a safe treatment option (Tab. 1, Ref. 14). Text in PDF www.elis.sk Keywords: durable mechanical assist device, durable left ventricular assist devices, outcomes, thromboembolic complications.

Temporal Analysis in Outcomes of Long-Term Mechanical Circulatory Support: Retrospective Study.

BACKGROUND: Mechanical assist device indications have changed in recent years. Reduced incidence of complications, better survival, and the third generation of mechanical support devices contributed to this change. In this single-center study, we focused on two time periods that are characterized by the use of different types of mechanical support devices, different patient characteristics, and change in the indications. METHODS: The data were processed from the European Registry for Patients with Mechanical Circulatory Support (EUROMACS). We retrospectively defined two time intervals to reflect changes in ventricular assist device technology (period 1: 2007-2015; period 2: 2016-20222). A total of 181 patients underwent left ventricular assist device implantation. Device utilization was the following: HeartMate II = 52 (76.4%) and HeartWare = 16 (23.6%) in period 1 and HeartMate II = 2 (1.8%), HeartMate 3 = 70 (61:9%), HeartWare = 29 (25.7%), SynCardia TAH = 10 (8.8%), and BerlinHeart EXCOR = 2 (1.8%) in period 2. The outcomes of the time intervals were analyzed and evaluated. RESULTS: Survival was significantly higher during the second time period. Multivariate analysis revealed that age and bypass pump time are independent predictors of mortality. Idiopathic cardiomyopathy, bypass time, and the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) score are independent predictors of adverse events. Furthermore, the first period was noted to be at an increased risk of the following adverse events: pump thrombosis, gastrointestinal bleeding, and bleeding events. CONCLUSION: Despite the higher risk profile of the patients and persistent challenges, during the second period, there was a significant decrease in mortality and morbidity. The use of the HeartMate 3 device may have contributed to this result.

Comparison of PCO2gap, SvO2 and plasmatic lactate in patients on venoarterial extracorporeal circulation support.

BACKGROUND: Clinical assessment and laboratory markers provide valuable information on tissue perfusion and enhance the optimalisation of management in the treatment of patients on extracorporeal membrane oxygenation (ECMO). The PCO2 gap is a reliable marker of cardiac output (CO) and perfusion. The aim of this study was to evaluate the PCO2 gap as a marker of tissue hypoperfusion and to compare it to lactate and SvO2. METHODS: A single-center retrospective study on 131 adult cardiac patients who underwent ECMO implantation in the period between 2010 and 2021. Baseline characteristics, laboratory markers and mortality were analyzed. RESULTS: There was a statistically significant difference in the plasmatic levels of lactate, SvO2 and PCO2 gap between patients that survived and those who died post ECMO implantation (3.6±3.29 vs 7.15±7.38 mmol/l, p<0.001; 69.13±9 vs 67.38±10%, p<0.001; 7.65±2.93 vs 8.34±3.71, p<0.001 respectively). There was a statistically significant difference in PCO2 gap in the first 5 arterial blood gas (ABG) samples post ECMO implantation between patients that survived and those who died (9.08±4.79 vs 10.37±5.35, p<0.003). For SvO2, this difference was not statistically significant (69.82±11.91 vs 68.51±11.72, p<0.104). There was a statistically significant but low negative correlation between SvO2 and PCO2 gap post ECMO implantation (r = ‒0.354, p<0.001). CONCLUSION: The PCO2 gap is a valuable biomarker for monitoring tissue perfusion in patients on ECMO. It is associated with increased mortality and should be an integral part of clinical evaluation. (Tab. 1, Fig. 5, Ref. 26). Text in PDF www.elis.sk Keywords: PCO2 gap, VA-ECMO, lactate.

Multivessel Coronary Disease and Severe Atherosclerotic Aorta: Real-World Experience.

Background and Objectives: Surgical revascularisation of patients with atherosclerosis of the ascending aorta remains a challenge. Different surgical strategies have been described in coronary surgical patients to offer alternative revascularisation strategies other than the conventional surgical revascularisation in patients unsuitable for it. The aim of this study is to compare the real-world outcomes between two groups of patients who underwent off-pump surgery (left internal mammary artery graft to the left anterior descending artery) or a hybrid with a percutaneous revascularisation procedure at a later stage. Materials and Methods: This is a single-centre retrospective observational study. Between the years 2010 and 2021, 91/6863 patients (1.33%) were diagnosed with severe atherosclerosis of the ascending aorta. All the patients were treated with off-pump revascularisation (91 patients), and the cardiologist would decide at a later stage whether the rest of the vessels would be treated with percutaneous revascularisation (25 patients). Results: There was no statistical difference in the various preoperative characteristics, except for coronary artery left main disease (30.30% vs. 64%; p = 0.0043). The two groups had no statistical differences in the perioperative characteristics and postoperative complications. The 1-, 5-, and 10-year mortality rates in the two groups were 6.1% vs. 0%, 59% vs. 80%, and 93.9% vs. 100%, respectively (off-pump vs. hybrid with percutaneous revascularisation procedure, p = 0.1958). Conclusions: Both strategies have high long-term comparable mortality. The off-pump surgery and the HCR procedure at a later stage may be solutions for these high-risk patients, but the target treatment should be complete HCR revascularisation during the index hospitalization.

Surgery for cardiac myxomas: 12-year experience.

INTRODUCTION: Cardiac myxoma is a rare benign cardiac tumor observed in approximately 0.5-1 case per 1 million people per year. The aim of this study is to review our 12-year experience in the surgical treatment of cardiac myxoma with an emphasis on the clinical, pathologic, diagnostic, and surgical features. METHODS AND PATIENTS: From January 2010 to December 2022, 90 patients (0.67 %) with cardiac myxomas were surgically treated in our institute. Patients´ demographics, cardiac and surgical medical history, surgical procedures, and pre- and post-operative data were analyzed. The median follow-up time was 76 (1-216) months. RESULTS: The mean age of the patients was 59.4 ± 13.5 years, with a higher prevalence of women. The most common preoperative symptoms were arterial embolism and dyspnea, and 35.6 % of patients were asymptomatic. Only 8.9 % of the patients had systemic and constitutional manifestations. The most common location of cardiac myxoma was in the left atrium, followed by the right atrium. Recurrent myxoma developed in 3 patients (2.7 %), and the mean time of recurrence was 55 ± 19.7. Hospital and long-term mortality were 2.2 % and 15.6 %, respectively. CONCLUSION: Cardiac myxoma is the most common heart tumor with a low incidence. Surgical excision yields very good short and long-term outcomes with low recurrence rate after surgery, and remains the treatment of choice (Tab. 4, Fig. 2, Ref. 13). Text in PDF www.elis.sk Keywords: cardiac myxoma, cardiac tumor, recurrence, survival.

Molecular hydrogen: prospective treatment strategy of kidney damage after cardiac surgery.

Cardiac surgery-associated acute kidney injury is a common post-operative complication, mostly due to increasing oxidative stress. Recently, molecular hydrogen (H2 gas) has also been applied to cardiac surgery due to its ability to reduce oxidative stress. We evaluated the potential effect of H2 application on the kidney in an in vivo model of simulated heart transplantation. Pigs underwent cardiac surgery within 3 h while connected to extracorporeal circulation (ECC) and subsequent 60 min of spontaneous reperfusion of the heart. We used two experimental groups: T-pigs after transplantation and TH-pigs after transplantation treated with 4% H2 mixed with air during inhalation of anesthesia and throughout oxygenation of blood in ECC. The levels of creatinine, urea and phosphorus were measured in plasma. Renal tissue samples were analyzed by Western blot method for protein levels of nuclear factor erythroid 2-related factor 2 (Nrf2), Kelch-like ECH-associated protein 1 (Keap-1), and superoxide dismutase (SOD1). After cardiac surgery, selected plasma biomarkers were elevated. However, H2 therapy was followed by the normalization of all these parameters. Our results suggest activation of Nrf2/Keap1 pathway as well as increased SOD1 protein expression in the group treated with H2. The administration of H2 had a protective effect on the kidneys of pigs after cardiac surgery, especially in terms of normalization of plasma biomarkers to control levels.

Adult cardiac surgery report 2021: The annual report from the Registry of the National Institute of Cardiovascular Diseases.

INTRODUCTION: Based on a longtime voluntary registry founded by the Ministry of Healthcare of the Slovak Republic in 2012 and endorsed by the National Institute of Cardiovascular Diseases, well-defined data of all adult cardiac surgery procedures performed during the year 2021 are analyzed. MATERIAL AND METHOD: For this period, data on 947 procedures were submitted to the registry. RESULTS: The unadjusted in-hospital survival rate for the 352 isolated coronary artery bypass grafting procedures including urgent and emergency procedures (relationship on-/off pump 3.8 : 1) was 96.3 %. For 331 isolated heart valve procedures (33 transcatheter interventions), it was 95.5 %. Concerning ventricular assist devices, 19 implantations were registered. In 2021 the number of isolated heart transplantations was 16, which is a decrease by 38.5 % as compared to the previous year. CONCLUSION: These annually registered data are collected from voluntary public reporting and accumulate actual information on nearly all heart procedures carried out in the National Institute of Cardiovascular Diseases. These data capture advancements in heart medicine and represent the basis for quality management. In addition, the registry demonstrates that the provision of cardiac surgery in Slovakia is up to date, appropriate, and nationwide patient treatment is guaranteed all the time (Tab. 14, Fig. 2, Ref. 5). Text in PDF www.elis.sk Keywords: heart valve surgery, outcomes, coronary artery bypass grafting, aortic surgery, heart transplantation.

Successful support of biventricular heart failure in an adult patient by the Berlin Heart EXCOR system as a bridge to transplant: literature review.

Right heart failure is a huge challenge in left ventricular assist device therapy and its occurrence is associated with increased mortality and morbidity. Other options include the use od temporary right ventricular assist device, use of two continous flow biventricular assist devices, use of total artificial heart and the use of paracorporeal biventricular assist devices.In this report we described the successful use of the paracorporeal pulsatile Berlin Heart EXCOR system as a bridge to transplant in a 62 years old patient with end-stage biventricular heart failure (Tab. 1, Fig. 3, Ref. 22). Keywords: biventricular heart failure, mechanical circulatory support, biventricular assist device, Berlin Heart EXCOR system, heart transplantation.

Transient reduction in ejection fraction following aortic valve replacement for aortic regurgitation.

BACKGROUND: In patients following aortic valve replacement (AVR) for aortic regurgitation, a transient reduction in ejection fraction (TREF) sometimes occurs in the postoperative period without a clear remediable cause, which leads to a spontaneous improvement without the need for a specific treatment. OBJECTIVE: To study the incidence and risk factors of TREF following AVR for aortic regurgitation. METHODS: We designed a single-centre retrospective observational study. A total of 164 patients were enrolled in the study: 82 in the regurgitation group and 82 in the stenosis group. Data were obtained from international registries and patient documentation. RESULTS: There were statistically significant differences in TREF between the regurgitation and stenosis groups (9.76 % and 0 %, respectively, p = 0.004). There was zero hospital mortality in both regurgitation and stenosis groups. The presence of TREF had no impact on long-term survival. CONCLUSION: Our results show that transient reduction in ejection fraction is a relatively common phenomenon following aortic valve replacement for aortic regurgitation and that in our study population it had no effect on short- and long-term survival (Tab. 2, Fig. 1, Ref. 15).

Indications, Complications, and Outcomes of Cardiac Surgery After Heart Transplantation: Results From the Cash Study.

Background: Allograft pathologies, such as valvular, coronary artery, or aortic disease, may occur early and late after cardiac transplantation. Cardiac surgery after heart transplantation (CASH) may be an option to improve quality of life and allograft function and prolong survival. Experience with CASH, however, has been limited to single-center reports. Methods: We performed a retrospective, multicenter study of heart transplant recipients with CASH between January 1984 and December 2020. In this study, 60 high-volume cardiac transplant centers were invited to participate. Results: Data were available from 19 centers in North America (n = 7), South America (n = 1), and Europe (n = 11), with a total of 110 patients. A median of 3 (IQR 2-8.5) operations was reported by each center; five centers included ≥ 10 patients. Indications for CASH were valvular disease (n = 62), coronary artery disease (CAD) (n = 16), constrictive pericarditis (n = 17), aortic pathology (n = 13), and myxoma (n = 2). The median age at CASH was 57.7 (47.8-63.1) years, with a median time from transplant to CASH of 4.4 (1-9.6) years. Reoperation within the first year after transplantation was performed in 24.5%. In-hospital mortality was 9.1% (n = 10). 1-year survival was 86.2% and median follow-up was 8.2 (3.8-14.6) years. The most frequent perioperative complications were acute kidney injury and bleeding revision in 18 and 9.1%, respectively. Conclusion: Cardiac surgery after heart transplantation has low in-hospital mortality and postoperative complications in carefully selected patients. The incidence and type of CASH vary between international centers. Risk factors for the worse outcome are higher European System for Cardiac Operative Risk Evaluation (EuroSCORE II) and postoperative renal failure.

The European Registry for Patients with Mechanical Circulatory Support of the European Association for Cardio-Thoracic Surgery: third report.

OBJECTIVES: In the third report of the European Registry for Patients with Mechanical Circulatory Support of the European Association for Cardio-Thoracic Surgery, outcomes of patients receiving mechanical circulatory support are reviewed in relation to implant era. METHODS: Procedures in adult patients (January 2011-June 2020) were included. Patients from centres with <60% follow-ups completed were excluded. Outcomes were stratified into 3 eras (2011-2013, 2014-2017 and 2018-2020). Adverse event rates (AERs) were calculated and stratified into early phase (<3 months) and late phase (>3 months). Risk factors for death were explored using univariable Cox regression with a stepwise time-varying hazard ratio (<3 vs >3 months). RESULTS: In total, 4834 procedures in 4486 individual patients (72 hospitals) were included, with a median follow-up of 1.1 (interquartile range: 0.3-2.6) years. The annual number of implants (range: 346-600) did not significantly change (P = 0.41). Both Interagency Registry for Mechanically Assisted Circulatory Support class (classes 4-7: 23, 25 and 33%; P < 0.001) and in-hospital deaths (18.5, 17.2 and 11.2; P < 0.001) decreased significantly between eras. Overall, mortality, transplants and the probability of weaning were 55, 25 and 2% at 5 years after the implant, respectively. Major infections were mainly noted early after the implant occurred (AER<3 months: 1.44 vs AER>3 months: 0.45). Bilirubin and creatinine levels were significant risk factors in the early phase but not in the late phase after the implant. CONCLUSIONS: In its 10 years of existence, EUROMACS has become a point of reference enabling benchmarking and outcome monitoring. Patient characteristics and outcomes changed between implant eras. In addition, both occurrence of outcomes and risk factor weights are time dependent.

The efficiency of the preoperative extracorporeal membrane oxygenation in the setting of postinfarction ventricular septal defect and how to optimize outcomes: A single center case series.

The mortality rate after the development of postinfarction ventricular septal defect remains high despite progress in pharmacologic therapy, invasive cardiology, and surgical techniques. We present a case series of six patients with preoperative venoarterial extracorporeal membrane oxygenation as a bridge to reparative surgical repair. Venoarterial extracorporeal membrane oxygenation allows to hemodynamically stabilize the patient, and safely delay the surgery. Delayed surgery might facilitate successful repair by allowing friable tissue to organize, strengthen, and become well-differentiated from surrounding healthy tissue; thus, definite repair can be performed safely. All patients were in cardiogenic shock and would otherwise require emergent cardiac surgery with associated risk. Three patients were discharged, with one hospital mortality of a patient who had a successful bridge to corrective surgery and died due to pulmonary artery rupture after a right ventricular assist device implantation. Two patients died before surgery while they were supported by venoarterial extracorporeal membrane oxygenation due to vascular complications. We discuss strategies how to optimize the management and function of the venoarterial extracorporeal membrane oxygenation to decrease the rate of adverse effects and optimize the outcomes of these patients.

Preoperative extracorporeal membrane oxygenation for postinfarction ventricular septal defect: Case series of three patients with a literature review.

The mortality rate after the development of postinfarction ventricular septal defect (VSD) remains high, despite progress in pharmacologic therapy, invasive cardiology, and surgical techniques. We present three cases of preoperative venoarterial extracorporeal membrane oxygenation as a bridge to reparative surgical repair in patients with cardiogenic shock who would otherwise require emergent cardiac surgery with an associated risk. Two patients were discharged, whereas the third patient died due to pulmonary artery rupture after a right ventricular assist device implantation, despite the fact that he had a successful bridge to reparative surgery and VSD repair. Finally, a review of the current literature concerning the use of preoperative venoarterial extracorporeal membrane oxygenation as a bridge to reparative surgery is provided.