Association between left ventricular ejection fraction and mortality after Bentall procedure.

Root infection or dissection involving coronary artery frequently necessitates an emergent Bentall procedure, with low left ventricular ejection fraction (LVEF). In contrast, concerning an elective Bentall for aneurysm, surgeons should balance the risk and benefit of surgery, especially in low LVEF cases. We investigated the association between preoperative LVEF and outcomes after Bentall. We analyzed 98 patients undergoing Bentall between April 2000 and March 2020. The patients were stratified into three groups: (a) 65 with LVEF ≥ 60%, (b) 21 with LVEF 45 to < 60%, and (c) 12 with LVEF < 45%. Baseline characteristics, survivals, and major adverse cardiovascular events (MACE) were compared. To assess potential non-linear relationship between LVEF and mortality, cubic spline analysis was conducted. Median age was similar (a vs b vs c, 52 vs 50 vs 44). In all groups, elective root aneurysm was 50-60%, indicating the rest were complicated and sick. Operative mortality was the highest in group c (4.6% vs 9.5% vs 16.7%, p = 0.294). Survival and MACE-free rate were the worst in group c, though their 10-year survival was 40%. LVEF was an independent risk for mortality, and cubic spline analysis showed potential non-linear association between LVEF and mortality. Although LVEF is an independent predictor of mortality after Bentall, long-term survival was occasionally achieved in low LVEF cases. While surgeons should carefully balance the risk of low LVEF and the benefit of surgery in elective cases, we should perform a non-elective procedure as needed, even if LVEF is low.

Long-term support by left ventricular assist device for arrhythmogenic right ventricular cardiomyopathy.

Arrhythmogenic right ventricular cardiomyopathy (ARVC) is a heart muscle disorder characterized by right ventricular enlargement, right heart failure (HF), and ventricular arrhythmias which lead to sudden death especially in young adults. Current recommendations for management of patients with ARVC are antiarrhythmic medications, catheter ablation, and implantable cardioverter defibrillator therapy to prevent sudden cardiac death. However, despite these treatments, few patients suffer from recurrent ventricular arrhythmias or HF unresponsive to conventional management. Heart transplantation (HTx) is a preferred treatment for these cases, but because of a persistent donor heart shortage in Japan, ventricular assist device (VAD) support has become an important option for a management of the end-stage ARVC. Previous articles reported 4 cases of a successful management by left ventricular assist device (LVAD), but the longest interval of LVAD support was only 333 days. We present 3 cases of ARVC patients who were successfully managed by LVAD implantation for more than a year. These 3 cases are unconventional examples of ARVC patients, considering the nature of the disease. The novelty of these cases should be taken in the context of the extremely long waiting period for HTx in Japan.

Enormous Aneurysm in Coronary Artery Fistula With Immunoglobulin G4-Related Disease.

We report the first case of coronary artery fistula with aneurysmal change in a patient with immunoglobulin G4-related disease (IgG4-RD). This case revealed concomitant coronary artery dilation, pericardial inflammatory nodules, and coronary-pulmonary fistula aneurysm in addition to several IgG4-RD lesions. Each of these features was located in close proximity to the thickened pericardium. These lesions might result from inflammation of the pericardial space, which extended to the coronary-pulmonary artery vessels, leading to aneurysmal formation. This case will enhance our understanding of the pathological mechanisms of IgG4-RD inflammation.

Hybrid Lead Extraction Technique: Combined Transatrial Laser Lead Extraction and Surgical Removal of Calcified Lesions.

This report presents a new hybrid lead extraction technique combined with transatrial laser lead extraction and surgical removal of calcified lesions in a 50-year-old man with superior vena cava syndrome and bilateral subclavian vein occlusion caused by an abandoned lead, which had been infected for 11 years. (Level of Difficulty: Intermediate.).

Single-center experience of the bridge-to-bridge strategy using the Nipro paracorporeal ventricular assist device.

Currently, we use the Nipro paracorporeal VAD (p-VAD) for initial short-term ventricular support, as a bridge to decision (BTD) or a bridge to candidacy (BTC) treatment, in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) levels 1 and 2 patients. However, it is possible that compared to patients with primary implantable-VADs (P-iVAD), the bridge-to-bridge (BTB) patients are more likely to develop complications. This retrospective study used data from 24 consecutive BTB patients who were initially implanted with Nipro p-VAD as BTD or BTC treatments between April 2011 and March 2016, and subsequently underwent conversion to an i-VAD. The data from 72 patients who underwent a primary i-VAD (P-iVAD) procedure were used for comparison. Between the two groups, there was no significant difference in the incidence of infectious events (p = 0.72) or stroke (p = 0.44). Orthotropic heart transplantation was performed in 6 of the 24 patients in the BTB group and in 21 of the 72 patients in the P-iVAD group. The 1- and 2-year survival rates were 95.8% and 95.8% in the BTB group and 91% and 85.8% in the P-iVAD group; these values were not significantly different between groups (p = 0.91). Based on these results we conclude that BTB using Nipro p-VAD is a reasonable strategy for treating patients with severe decompensated end-stage heart failure.

Novel driveline route for prevention from driveline infection: Triple tunnel method.

BACKGROUND: The most prevalent and serious infection related to left ventricular assist devices (LVADs) is driveline infection (DLI). From 2014, we employed a revised surgical technique (triple tunnel method), which deployed a longer subfascial driveline (DL) route. METHODS AND PATIENTS: We retrospectively analyzed 34 patients fitted with either of the two types of axial pumps: HeartMate II (n=23) and Jarvik 2000 (n=11). Prior to 2014, the DL proceeded from the pump pocket just above the posterior sheath of the rectus muscle toward a vertical skin incision at the right lateral border of the rectus muscle. Then, DL was turned leftward into the subcutaneous tissue to redirect its exit to the left side [subcutaneous tissue group (Group S): n=14]. From 2014, we made an additional skin incision below the umbilicus with the aim of lengthening the subfascial DL route [muscle group (Group M): n=20]. RESULTS: DLI occurred in 10 patients (71.4%) in Group S and in 1 patient (5%) in Group M (p<0.05, Chi-square test). The freedom rate from re-admission at 1 year due to DLI was 64% in Group S and 95% in Group M, respectively (p=0.021, log-rank test). Furthermore, logistic regression analysis revealed that DL route was significantly associated with DLI (odds ratio, 10.1; 95% confidence interval, 1.15-275.3). CONCLUSION: Although a longer follow-up period will be needed, the triple tunnel method may be beneficial in the prevention of DLI.

The Incidence, Risk Factors, and Outcomes of Hyperlactatemia after Heart Transplantation.

Hyperlactatemia (HL) is associated with tissue hypoperfusion during cardiac surgery, which results in postoperative morbidity and mortality among patients undergoing cardiopulmonary bypass surgery. The aim of this study was to determine the incidence, risk factors, and outcome of HL after heart transplantation (HTx) in one of the largest Japanese single-center cohorts. We retrospectively studied the lactate levels in 49 patients who underwent HTx at the University of Tokyo Hospital from August 1, 2010 to November 30, 2015. All of the patients were over 20 years of age. Arterial blood samples were analyzed during the operation and until 24 hours after surgery. Twenty-nine patients (59.2%) had HL after intensive-care unit admission. At 24 hours after surgery, the lactate levels of all patients had recovered to the normal range. A multivariate analysis showed that the total ischemic time of the donor heart (odds ratio [OR], 1.0176; 95% confidence interval [CI], 1.0004-1.0375; P = 0.0444) and the duration of preoperative left ventricular assist device (LVAD) support (OR, 0.9977; 95% CI, 0.9952-0.9997; P = 0.0218) were risk factors for HL. Pulmonary complications were noted in 24.1% of the patients with high lactate values but in none of the patients without HL (P = 0.0182); however, there were no cases of hospital death, and the length of hospital stay did not differ to a statistically significant degree between HL groups (P = 0.719). Although HL after HTx was common, it appeared to be transient and benign. Donor heart ischemia and the duration of preoperative LVAD support were associated with HL after transplantation.

Readmissions after continuous flow left ventricular assist device implantation.

Continuous flow left ventricular assist device (CF-LVAD) therapy has improved the survival of patients with advanced heart failure. However, the readmission rate of CF-LVAD patients is still relatively high. A total of 90 patients who received CF-LVADs between April 2011 and March 2016 at our institute and were discharged home were analyzed retrospectively. They were followed up through March 2017. Clinical data, including frequency, length and etiology of readmission, were obtained from medical records. The mean observation period after initial discharge was 713 ± 322 days. In total, 73 patients (81%) had 236 readmissions, 214 unplanned and 22 planned. The overall and unplanned readmission rates were 1.34 and 1.22 per patient-year, respectively. The rate of freedom from unplanned first readmission at 1 year after initial discharge was 39%. The median interval between the previous hospital discharge and first and second readmissions was 311 and 213 days, respectively (log-rank test, p = 0.117). The rate of readmission after more than three readmissions was significantly higher than that of first or second readmission (log-rank test, p < 0.001). The most common etiology of readmission was driveline infection (DLI) (36%), followed by stroke (9%). The median length of hospital stay due to DLI was 23 days. The patients with repeated unplanned readmissions had significantly lower EuroQol 5 dimensions questionnaire utility score than those with no or just one readmission. Readmission was common in CF-LVAD patients, and the most common etiology of readmissions was DLI. The interval to the next readmission seemed shorter for patients with repeated readmissions.

Successful management of apical abscess after Nipro left ventricular assisted device explantation by removal of apical cuff and omentopexy.

Nipro-Toyobo-paracorporeal pulsatile flow VAD (Nipro VAD; Nipro, Osaka, Japan) has been used most commonly as a paracorporeal VAD (p-VAD) in Japan. There are few reports describing clinical course of post LVAD explantation and its complication. We herein present two cases of apical abscess after the explantation of the device. SSI is a main risk factor of formation of the apical abscess at the time of LVAD explantation. It is mandatory to perform sufficient debridement and closure of the layers including abdominal muscle and anterior abdominal fascia at exit sites in the explantation surgery. Omentopexy is also helpful for prevention from infection. Routine removal of apical cuff and outflow graft could be considered as one of the options when LVAD is explanted as bridge to recovery.

[Temporary use of centrifugal pump for pump thrombosis in patients with paracorporeal ventricular assist device].

Nipro paracorporeal ventricular assist device( VAD) is often associated with pump thrombosis which causes severe complications such as brain infarction, often requiring pump change. However, Nipro VAD pump is an expensive device and it is difficult to change pumps frequently at a short interval. We have temporarily used Rotaflow centrifugal pump for recurrent pump thrombosis in patients with Nipro VADs. From January 2012 through December 2013, 19 patients underwent Nipro VADs implantation at our institution, and 9 of them underwent pump change from Nipro pumps to Rotaflow centrifugal pumps. A total of 25 Rotaflow centrifugal pumps were used in these 9 patients, with the total circulatory support duration of 526 days. The median support period was 15 days (range;2-128 days). There were 2 cerebrovascular accidents and 1 Rotaflow pump circuit thrombosis during this period. Change from Rotaflow to Nipro VAD pump resulted in decrease in hematocrit by about 3 point. There was no difference in liver or renal function between before and after the pump change. Our results suggest that temporary use of Rotaflow centrifugal pump for recurrent pump thrombosis in patients with Nipro VADs may be a promising alternative.

Negative pressure wound therapy for left ventricular assist device-related mediastinitis: two case reports.

We report two cases of successful use of negative pressure wound therapy (NPWT) to control of left ventricular assist device (LVAD)-related mediastinitis. It is difficult to treat mediastinitis in patients who have undergone LVAD implantation, because it is impossible to remove the infected artificial materials from the mediastinal space. This report indicates that NPWT might become the preferred therapeutic option for control of mediastinitis in patients who have undergone LVAD implantation.