Influence of gender on postoperative outcome after intra-aortic balloon counter-pulsation and cardiac surgery.

INTRODUCTION: Female gender is an established risk factor for worse outcomes after cardiac surgery, and women are more likely to experience postoperative complications. Our aim was to analyze the influence of gender on outcome and postoperative complications after the use of intra-aortic balloon counter-pulsation (IABP) in cardiac surgery patients. METHODS: Fifty-seven consecutive female patients (mean age: 73 ± 9 years) requiring an IABP at our department from January 2007 to January 2010 were retrospectively analyzed and compared with 182 male patients receiving IABP support within the same period. The collected data included patient demographics, preoperative state, operative details, postoperative pharmacological treatment, IABP-associated complications, and inhospital mortality. Preoperative mortality risk was calculated by logistic EuroSCORE. RESULTS: There were no differences regarding the type of operation, preoperative renal or hepatic failure, though the prevalence of peripheral artery occlusive disease was higher in men. Furthermore, female patients receiving an IABP were significantly older (73 ± 9 vs. 67 ± 10 years), had a higher ejection fraction (EF) (45% ± 24% vs. 36% ± 14%), and had a higher EuroSCORE (25% ± 20% vs. 19% ± 17%; p < 0.05). Postoperative catecholamine support was significantly higher in the female patients. Women had a prolonged length of stay (LOS) at the ICU (10.64 ± 9.7 vs. 7.6 ± 7.6 days), higher incidence of renal replacement therapy, and a higher mortality (19 [19.4%] vs. 35 [33.9%]; p < 0.05) after the use of IABP. CONCLUSION: Women have a worse outcome after the use of IABP, including LOS at the ICU, postoperative renal failure, and inhospital mortality, despite higher EF, when compared with men.

Daptomycin as supportive treatment option in patients developing mediastinitis after open cardiac surgery.

BACKGROUND: Mediastinitis is a severe complication after cardiac surgery. While improvement of prophylaxis and of medical and surgical therapy has reduced its incidence, the treatment of mediastinitis continues to be a challenging problem. Within this study, we report the successful use of daptomycin as supportive therapy in patients developing mediastinitis after open cardiac surgery. METHODS: The records of 21 consecutive patients who developed mediastinitis after cardiac surgery were retrospectively reviewed. After diagnosis, all patients received surgical debridement and antibiotic therapy with daptomycin. All patients were followed up to death or discharge. RESULTS: Clinical improvement after combined surgical and antibiotic therapy with daptomycin was found in 90.5% of the patients. The median time until clinical improvement occurred was 5 [4/6] days. Daptomycin was well-tolerated and no major adverse events during therapy were observed observed. CONCLUSIONS: This study provides new and helpful information regarding the beneficial use of daptomycin as supportive treatment option in patients developing mediastinitis after cardiac surgery.

Surgical strategy for biventricular assist device implantation after previous coronary artery bypass grafting.

In an aging population, numerous patients who underwent previous coronary artery bypass grafting (CABG) are presenting with end-stage ischemic cardiomyopathy. Although redo CABG and cardiological interventions are possible treatment options, orthotopic heart transplantation remains an ultimate option for these patients. However, there is high morbidity and mortality on the waiting list, and mechanical circulatory support is a life-saving concept [Hetzer 2006; Taylor 2009].We developed a simplified and safe technique for implantation of a biventricular assist device as a redo in complex patients after previous CABG and end-stage heart failure.

Heparin-induced thrombosis without thrombocytopenia causing fulminant pulmonary embolism after off-pump coronary artery bypass grafting.

Heparin-induced thrombocytopenia (HIT) is a rare immune-mediated complication of heparin administration. A potentially life-threatening complication, HIT is difficult to diagnose in patients in the intensive care unit after cardiac surgery because there can be multiple reasons for thrombocytopenia. Moreover, immune-mediated platelet consumption may be masked by reactive thrombocytosis, which is common in the typical postoperative course after cardiac surgery. We report the case of a 57-year-old male patient who developed fulminant pulmonary embolism following heparin-induced thrombosis without thrombocytopenia after off-pump coronary artery bypass surgery.

Hirudin for management of heparin-induced thrombocytopenia type II in a patient with biventricular assist device support.

A patient with severe dilated cardiomyopathy developed heparin-induced thrombocytopenia type II (HIT II) after implantation of a biventricular assist device (biVAD). Because the patient showed mild renal dysfunction but severe hepatic impairment, the management of anticoagulation was switched from heparin to the direct thrombin inhibitor hirudin, which was administered by continuous infusion of 0.6 to 1 mg/h. This protocol was monitored by measuring the plasma hirudin level, which ranged from 0.5 to 1.5 microg/mL. Unfortunately, the patient died on day 22 after implantation from fulminant sepsis caused by Aspergillus fumigatus. Neither thromboembolic events nor thrombocytopenia was observed after hirudin administration. The explanted biVAD showed no thrombotic material in the arterial/venous lines or on the polyurethane valves. We discuss the challenges posed by HIT II complicating VAD support as well as its clinical management with direct thrombin inhibitors.

Extracorporeal support in a patient with cardiogenic shock due to Aerococcus urinae endocarditis.

Aerococcus urinae is a newly identified Gram-positive coccus that causes serious infections. To date, only 15 cases of A. urinae infective endocarditis have been reported, but with a very high mortality. The case is reported of a patient with A. urinae double valve endocarditis. Following aortic and mitral valve replacement, the patient suffered from refractory cardiogenic shock; extracorporeal membrane oxygenation was used successfully as a rescue mechanical support.

Levosimendan: a new therapeutic option in the treatment of primary graft dysfunction after heart transplantation.

Primary graft dysfunction after heart transplantation is a severe complication generally related to prolonged ischemia time, size mismatch, or poor quality of the organ. Current therapeutic options include pharmacologic inotropic support with catecholamines or phosphodiesterase inhibitors, and mechanical circulatory support. We report 12 patients who received levosimendan, a new Ca(2+) sensitizer, as adjunctive inotropic support. The patients showed a rapid reduction of the doses of inotropic drugs, and no patient needed mechanical support. Levosimendan may be a useful, adjunctive inotropic drug in the treatment of patients with primary graft dysfunction after heart transplantation.

Acute profound thrombocytopenia after treatment with tirofiban and off-pump coronary artery bypass grafting.

The glycoprotein IIb/IIIa (GP IIb/IIIa) receptor antagonists prevent platelet aggregation and thrombus formation, improving outcomes of patients with acute coronary syndrome. Therapy with these agents may lead to bleeding complications and thrombocytopenia, challenging the perioperative management of patients undergoing coronary surgery. We report the successful management of an acute profound thrombocytopenia after urgent off-pump coronary surgery in a patient treated with tirofiban for unstable angina and acute coronary syndrome.

Huge intracardiac thrombosis in a patient on veno-arterial extracorporeal membrane oxygenation support.

A young woman suffering from congenital hypertrophic obstructive cardiomyopathy (HOCM) received a transcoronary ablation of the septal hypertrophy (TASH) and an automated Cardioverter/Defibrillator (AICD) for the relief of progressive symptoms of heart failure. She developed an acute heart failure in the perioperative period and had to be put on veno-arterial extracorporeal membrane oxygenation. Following this the patient developed a nearly complete thrombosis of the left-sided cardiac chambers, despite successful laboratory anticoagulation.

Esophageal perforation after catheterization of the subclavian vein.

The insertion of a central venous catheter (CVC) via the subclavian vein is often associated with complications. We report a case in which a patient suffered an esophageal lesion with severe bleeding and a pneumothorax with mediastinal shift induced by the insertion of the dilator of a CVC. The pneumothorax had to be treated immediately by pleural drainage, and the esophageal lesion was successfully corrected by means of an endoclip. The patient survived the complication. However, he died 1 week later from multiple organ failure not associated with the CVC insertion.

Daptomycin for eradication of a systemic infection with a methicillin-resistant-Staphylococcus aureus in a biventricular assist device recipient.

The rate of infection in patients who require ventricular assist devices is estimated at more than 35%. Infections with multi-resistant organisms such as methicillin-resistant Staphylococcus aureus in ventricular assist device recipients are often difficult to treat and present a high mortality rate. Daptomycin is a new cyclic lipopeptide antibiotic, useful in gram-positive organisms resistant to standard treatment. We report a case of a 65-year-old man suffering from a dilatative cardiomyopathy and concomitant MRSA infection who received a biventricular assist device. The patient had MRSA sepsis develop resistant to conventional therapy, which was successfully treated with daptomycin.

Levosimendan treatment after primary organ failure in heart transplantation: a direct way to recovery?

Heart transplantation is considered nowadays the gold standard in the therapy of chronic and terminal heart insufficiency. Primary organ failure after heart transplantation is a severe complication generally related to prolonged ischemia time, poor quality of the organ, or acute rejection. All these factors can potentially lead to multiorgan failure. Pharmacological and mechanical support for these patients is limited and often related to side effects. Ca sensitizers have been proposed to increase cardiac contractility without altering intracellular Ca levels, thus avoiding the side effects of Ca overload. We report two cases of heart transplanted patients suffering from acute graft failure in the early postoperative period who recovered after intravenous administration of levosimendan, a Ca sensitizer.

Morphological and functional magnetic resonance imaging after heterotopic heart transplantation.

In patients with severe congestive heart failure, a marked elevation in pulmonary vascular resistance limits the success of orthotopic cardiac transplantation, providing the rationale for heterotopic transplantation. In the case reported, cardiac anatomy and function of two hearts in the same chest were imaged using magnetic resonance imaging (MRI). MRI offers a high-resolution, three-dimensional, noninvasive technique to visualize the complex anatomy after heterotopic heart transplantation, providing information of morphologic and functional parameters at the same time. The challenge of sufficient electrocardiogram triggering, hindered by two hearts with electrophysiological activity in the same chest, can be overcome using new real-time techniques.