Practical Considerations for and Outcomes of Interfacility ECMO Transfer of Patients With COVID-19 During a Pandemic: Mayo Clinic Experience.

Interfacility transport of a critically ill patient with acute respiratory distress syndrome (ARDS) may be necessary for a higher level of care or initiation of extracorporeal membrane oxygenation (ECMO). During the COVID-19 pandemic, ECMO has been used for patients with severe ARDS with successful results. Transporting a patient after ECMO cannulation by the receiving facility brings forth logistic challenges, including availability of adequate personal protective equipment for the transport team and hospital capacity management issues. We report our designated ECMO transport team's experience of 5 patients with COVID-19-associated severe ARDS after cannulation at the referring facility. Focusing on transport-associated logistics, creation of checklists, and collaboration with emergency medical services partners is necessary for safe and good outcomes for patients while maintaining team safety.

Development of advanced conduction disturbances following balloon-expandable transcatheter aortic valve replacement leads to poorer clinical outcomes.

BACKGROUND: Transcatheter aortic valve replacement (TAVR) is a reliable method of treating patients with severe aortic stenosis, but is associated with postprocedure conduction defects. OBJECTIVE: The purpose of this study was to compare clinical outcomes in patients who developed advanced conduction defects post-TAVR to those who did not. METHODS: We conducted a retrospective chart review of 243 patients who underwent balloon-expandable TAVR with the Edwards Sapien valve to determine the incidence of advanced conduction defects in our cohort. We compared clinical outcomes including overall mortality, improvement in symptomatology, and improvement in left ventricular ejection fraction. RESULTS: Among the 243 patients included in the study, 9.1% (22/243) required permanent pacemaker (PPM); 19.8% (48/243) developed left bundle branch block (LBBB), and 71.2% (173/243) did not develop any permanent advanced conduction defects. Overall 1-year mortality was similar across all three groups. There was significant improvement in New York Heart Association functional capacity of all groups post-TAVR, but this was much less in the PPM group (45.5% vs 68.8%, P = .04). Postprocedure from TAVR, patients with LBBB or PM were less likely to have improvement in their ejection fraction (net loss of -0.7% for LBBB and -5.7% for PPM compared to a net gain of 2.3% for no-LBBB/PM (P = .02). CONCLUSION: Patients who develop LBBB or require PM post-TAVR with Edwards Sapien valves are less likely to improve New York Heart Association functional capacity and more likely to have no improvement or deterioration of their pre-TAVR left ventricular ejection fraction.

Left atrial appendage exclusion during mitral valve surgery and stroke in atrial fibrillation.

PURPOSE: The purpose of this study was to determine whether surgical left atrial appendage (LAA) exclusion performed during mitral valve surgery is associated with a reduction in cerebrovascular events in patients with atrial fibrillation. METHODS: We retrospectively studied patients with atrial fibrillation who underwent mitral valve surgery from 1/1/2001 through 12/31/2014. We screened 1352 patients using ICD-9 codes and included 281 patients in the study. The primary end point was a composite of strokes and transient ischemic attacks occurring within 5 years after surgery. Secondary end points were stroke, transient ischemic attack, and all-cause mortality. RESULTS: The LAA exclusion group (n = 188) had a lower prevalence of female gender, hypertension, and diabetes mellitus compared with the non-LAA exclusion group (n = 93). The CHA2DS2VASc scores were comparable between groups (2.6 vs 2.9, P = .11), as was anticoagulant use (82.4% vs 85.0%, P = .60). Concomitant surgical ablation was performed in 73.9% of patients who underwent LAA exclusion. Nine cerebrovascular events occurred in the LAA exclusion group and 13 in the non-LAA exclusion group (HR 0.30 [0.12-0.75], P = .01). There was no difference in all-cause mortality between groups. On multivariate analysis of the primary end point of strokes or transient ischemic attacks, significant variables were LAA exclusion (HR 0.31 [0.12-0.76], P = .01) and CHA2DS2VASc score (HR 1.44 [1.11-1.87], P = .006). The benefit of LAA exclusion was detected only when performed together with surgical ablation (HR 0.27 [0.09-0.72], P = .01). CONCLUSIONS: LAA exclusion was associated with fewer cerebrovascular events. However, this benefit was seen only with concomitant surgical ablation.

Left Ventricular Septal Hypertrophy in Elderly Patients With Aortic Stenosis.

OBJECTIVES: Left ventricular (LV) septal hypertrophy in aortic stenosis raises diagnostic and therapeutic questions. However, the etiology and clinical consequences of this finding have not been well studied. The aim of this study was to perform a morphologic evaluation of the LV in aortic stenosis and to investigate the contributing factors and consequences of septal hypertrophy. METHODS: Patients with moderate or severe aortic stenosis were prospectively enrolled. Patients with previous myocardial infarction, wall motion abnormalities, at least moderate valvular regurgitation, known cardiomyopathy, an LV ejection fraction of less than 50%, and age younger than 65 years were excluded. RESULTS: Forty-one patients underwent a final analysis. Septal hypertrophy (LV septal wall thickness ≥15 mm) was confirmed in 21 of 41 patients. The septal hypertrophy group had higher peak aortic valve velocity, a higher diabetes mellitus rate, and a higher rate and longer duration of hypertension than those without septal hypertrophy. The peak aortic valve velocity (odds ratio, 7.1; 95% confidence interval, 1.4-37.1) and diabetes mellitus (odds ratio, 7.4; 95% confidence interval, 1.2-46.2) were the significant factors associated with septal hypertrophy by multivariate analysis. Intraventricular conduction disturbance on electrocardiography was more frequent in the septal hypertrophy group (P = .021). CONCLUSIONS: Left ventricular septal hypertrophy was commonly observed in elderly patients with aortic stenosis, and a higher aortic valve velocity, hypertension, and diabetes mellitus were associated factors. Intraventricular conduction disturbance occurred more often in patients with septal hypertrophy than those without, which implies the pathophysiologic consequence. Further studies are needed to determine the impact of septal hypertrophy and intraventricular conduction disturbance on the prognosis of patients after aortic valve interventions.

The utility of live video capture to enhance debriefing following transcatheter aortic valve replacement.

BACKGROUND: The surgical and procedural specialties are continually evolving their methods to include more complex and technically difficult cases. These cases can be longer and incorporate multiple teams in a different model of operating room synergy. Patients are frequently older, with comorbidities adding to the complexity of these cases. Recording of this environment has become more feasible recently with advancement in video and audio capture systems often used in the simulation realm. AIMS: We began using live capture to record a new procedure shortly after starting these cases in our institution. This has provided continued assessment and evaluation of live procedures. The goal of this was to improve human factors and situational challenges by review and debriefing. SETTING AND DESIGN: B-Line Medical's LiveCapture video system was used to record successive transcatheter aortic valve replacement (TAVR) procedures in our cardiac catheterization/laboratory. An illustrative case is used to discuss analysis and debriefing of the case using this system. RESULTS AND CONCLUSIONS: An illustrative case is presented that resulted in long-term changes to our approach of these cases. The video capture documented rare events during one of our TAVR procedures. Analysis and debriefing led to definitive changes in our practice. While there are hurdles to the use of this technology in every institution, the role for the ongoing use of video capture, analysis, and debriefing may play an important role in the future of patient safety and human factors analysis in the operating environment.

Performance and Safety of an Integrated Portable Extracorporeal Life Support System for Adults.

Extracorporeal membrane oxygenation (ECMO) is indicated when conventional measures fail to support a patient during cardiac or respiratory failure. Due to the complicated nature of ECMO, patients often require transport to a tertiary care center. This study retrospectively compared the performance of the Cardiohelp™ (Maquet) life support system with a previously used ECMO circuit when transporting adult patients on venoarterial ECMO between facilities. Two ECMO circuits were compared for performance: 1) the Cardiohelp™ (Maquet) life support system and 2) the "standard" circuit consisting of a Thoratec CentriMag centrifugal pump, Maquet Quadrox-D oxygenator, and a Terumo CDI-500 in-line blood gas analyzer. After analyzing data from 16 patients (eight patients supported with each ECMO system), no differences in patient demographics, percentage of patients successfully weaned from ECMO, percentage of patients surviving to discharge, duration supported on the initial ECMO system, or total duration of ECMO were noted. No patient deaths were related to circuit failure or circuit disruptions in either group. Analysis of the performance of the ECMO circuits and the resulting patient status showed few significant differences between ECMO groups (Cardiohelp™ vs. standard circuit) and time points (the first 8 hours vs. a 24-hour time point). The statistically significant differences were not concerning in terms of appropriate medical support or patient safety. Of interest, the transmembrane pressure was significantly lower for the Cardiohelp™ module vs. the standard oxygenator during the first 8 hours (20.1 [5.3] vs. 37.1 [7.1] mmHg; p < .001) and at 24 hours (21.3 [3.8] vs. 34.8 [7.9] mmHg; p = .001). The Cardiohelp™ portable life support system provides safe and reliable support for adult patients on ECMO during interhospital patient transport as compared to the standard circuit.

Changing trends in abdominal surgical complications following cardiac surgery in an era of advanced procedures. A retrospective cohort study.

BACKGROUND: Abdominal complications following cardiopulmonary bypass (CPB) procedures may have mortality rates as high as 25%. Advanced procedures such as ventricular assist devices, artificial hearts and cardiac transplantation are being increasingly employed, changing the complexity of interventions. This study was undertaken to examine the changing trends in complications and the impact of cardiac surgery on emergency general surgery (EGS) coverage. METHODS: A retrospective review was conducted of all CPB procedures admitted to our ICU between Jan. 2007 and Mar. 2010. The procedures included coronary bypass (CABG), valve, combination (including adult congenital) and advanced heart failure (AHF) procedures. The records were reviewed to obtain demographics, need for EGS consult/procedure and outcomes. RESULTS: Mean age of the patients was 66 ± 8.5 years, 71% were male. There were 945 CPB procedures performed on 914 patients during this study period. Over 39 months, 23 EGS consults were obtained, resulting in 10 operations and one hospital death (10% operative mortality). CABG and valve procedures had minimal impact on EGS workload while complex cardiac and AHF procedures accounted for significantly more EGS consultations (p < 0.005) and operations (p < 0.005). The majority of consultations were for small bowel obstruction/ileus (n = 4, 17%), cholecystitis (n = 3, 13%) and to rule out ischemia (n = 2, 9%) CONCLUSIONS: In the era of modern critical care and cardiac surgery, advanced technology has increased the volume of complex CPB procedures increasing the EGS workload. Emergency general surgeons working in institutions that perform advanced procedures should be aware of the potential for general surgical complications perioperatively and the resultant nuances that are associated with operative management in this patient population.

Histologic remission of cardiac amyloidosis: a case report.

The main determinant of survival in amyloid light chain amyloidosis is cardiac involvement. The rate of change in wall thickness may be a strong predictor of survival. After treatment, some hematologic responders have had documented regression of wall thickness by echocardiography with resolution of heart failure symptoms. Herein, we demonstrate a case of treated immunoglobulin light chain cardiac amyloidosis with echocardiographic wall thinning and cardiac biopsies demonstrating complete histologic remission. This observation suggests a mechanism of treatment response and that with appropriately timed treatment, cardiac deposition of amyloid fibrils can be completely reversed.

Thrombography reveals thrombin generation potential continues to deteriorate following cardiopulmonary bypass surgery despite adequate hemostasis.

The intrinsic and extrinsic activation pathways of the hemostatic system converge when prothrombin is converted to thrombin. The ability to generate an adequate thrombin burst is the most central aspect of the coagulation cascade. The thrombin-generating potential in patients following cardiopulmonary bypass (CPB) may be indicative of their hemostatic status. In this report, thrombography, a unique technique for directly measuring the potential of patients' blood samples to generate adequate thrombin bursts, is used to characterize the coagulopathic profile in post-CPB patients. Post-CPB hemostasis is typically achieved with protamine reversal of heparin anticoagulation and occasionally supplemented with blood product component transfusions. In this pilot study, platelet poor plasma samples were derived from 11 primary cardiac surgery patients at five time points: prior to CPB, immediately post-protamine, upon arrival to the intensive care unit (ICU), 3 hours post-ICU admission, and 24 hours after ICU arrival. Thrombography revealed that the Endogenous Thrombin Potential (ETP) was not different between [Baseline] and [PostProtamine] but proceeded to deteriorate in the immediate postoperative period. At the [3HourPostICU] time point, the ETP was significantly lower than the [Baseline] values, 1233 +/- 591 versus 595 +/- 379 nM.min (mean +/- SD; n=9, p < .005), despite continued adequacy of hemostasis. ETPs returned to baseline values the day after surgery. Transfusions received, conventional blood coagulation testing results, and blood loss volumes are also presented. Despite adequate hemostasis, thrombography reveals an underlying coagulopathic process that could put some cardiac surgical patients at risk for postoperative bleeding. Thrombography is a novel technique that could be developed into a useful tool for perfusionists and physicians to identify coagulopathies and optimize blood management following CPB.

Occurrence of left-sided heart valve involvement before right-sided heart valve involvement in carcinoid heart disease.

Carcinoids are rare neuroendocrine tumours that occur primarily in the gastrointestinal tract. Carcinoid heart disease is characterized by fibrous plaque deposition on the endocardial surface of the cardiac valves and chambers. It affects the right heart valves in 85% of cases and the left heart valves in 15%. We present an unusual case of a patient with metastatic carcinoid heart disease in whom typical carcinoid aortic and mitral valve lesions developed 2 years prior to the development of severe right-sided carcinoid valvular heart disease.

Surgery for pulmonary coccidioidomycosis: a 10-year experience.

BACKGROUND: Coccidioidomycosis results from infection with Coccidioides species endemic to the southwestern United States. The mobile US population has resulted in incremental cases being found throughout the world. The fungal infection can result in pulmonary sequelae, including nodules, cavities, and complications requiring treatment by the thoracic surgeon. METHODS: A retrospective chart review was conducted of 1,496 patients with coccidioidomycosis treated at our institution (January 1998 to December 2008) to identify those requiring surgery. RESULTS: Of the 1,496 patients, 86 (6%; mean age, 58 years [range, 18 to 81], 48 women) underwent operations. Radiographs revealed 59 nodules, 18 cavities, 2 infiltrates, and 7 complications of disease (e.g., effusion, pneumothorax, and empyema). Of the 86 patients, 40% underwent resection for persistent symptoms or disease progression despite adequate antifungal therapy. One third of the operations were performed by video-assisted thoracoscopic surgery. Morbidity, 21% (18 patients), and in-hospital mortality, 2% (2 patients), were greater after resection for cavitary lesions with resultant complications versus for nodular disease: 41% versus 12% (p < or = 0.002) and 8% versus 0% (p < 0.005). Prolonged air leaks or bronchopleural fistulas were the most common complications (13 patients). Postoperative antifungal therapy was administered to 42% of patients (89% of cavitary and complicated). There were no cases of recurrence at follow-up (mean, 24 months). CONCLUSIONS: Surgical intervention was indicated for only a few patients, most commonly for diagnostic dilemmas involving nodular disease, symptomatic nonresponsive cavitary disease, or complications. Prolonged air leaks were the main cause of morbidity. Resection should result in symptom resolution and long-term freedom from recurrence.

Localized gastric or gastroesophageal cancer - chemoradiation is a pertinent component of adjuvant treatment for patients at high risk of relapse.

The standard of care for resectable gastric or gastroesophageal (GE) junction cancer for patients who can tolerate a surgical procedure is surgical resection, but surgery alone is not optimal treatment for patients at high risk for relapse. For patients with lower-risk lesions (confined to gastric wall, nodes negative; T1-2N0M0), local-regional relapse risks are low, and adjuvant radiotherapy is usually not recommended, except in select instances. Since both local-regional and systemic relapses are common after resection of high-risk gastric or GE junction cancers (beyond wall, nodes positive, or both; T3-4N0, TanyN+), adjuvant treatment is indicated for these patients. The results of phase III trials that demonstrate a survival benefit for adjuvant preoperative radiotherapy, postoperative chemoradiation, or preoperative chemoradiation vs. surgery alone will be presented and compared with the results of adjuvant perioperative chemotherapy. Results of Surveillance, Epidemiology, and End Results (SEER) analyses and meta-analyses that support the role of adjuvant radiotherapy or chemoradiation will be summarized.

Use of an inexpensive blue band during ventricular assist device and total artificial heart placement facilitates and expedites explantation during heart transplant.

Ventricular assist devices and total artificial hearts are now being used routinely as a bridge to heart transplantation. Reoperation is often weeks to months from implantation. Difficulty dissecting mediastinal and cardiac structures is often encountered due to adhesion formation that prolongs operative time. A temporary, flexible, rectangular-shaped polyisoprene blue band is used to encircle major vascular structures. We have found that this facilitates identification, reduces adhesion formation, and expedites device removal at the time of heart transplantation.

Coccidioidal pericarditis: implications of surgical treatment in the elderly.

Coccidioidal pericarditis, an uncommonly diagnosed entity, may evolve to a constrictive process. Constrictive coccidioidal pericarditis requires pericardiectomy and antifungal therapy. In the elderly, pericardiectomy may be complicated by coagulopathy and septic shock. Despite potential toxicity, use of antifungal therapy early postoperatively offers the best chance for survival.

Low-dose oral amiodarone prophylaxis reduces atrial fibrillation after pulmonary resection.

BACKGROUND: Atrial fibrillation after pulmonary resection increases morbidity and costs. To evaluate the efficacy of low-dose oral amiodarone (LDOA) as prophylaxis for atrial fibrillation after pulmonary resection, we reviewed all patients 60 years or older having pulmonary resections by thoracotomy in a 30-month period. METHODS: We identified 31 patients who received prophylactic LDOA (200 mg by mouth every 8 hours) while hospitalized and 52 patients who received no prophylactic treatment. The groups were comparable for sex, age, comorbidities, and surgical procedure. RESULTS: Twenty of 83 patients (24%) had postoperative atrial fibrillation: 17 of 52 patients (33%) without prophylaxis and 3 of 31 (9.7%) with prophylaxis (odds ratio, 0.221; 95% confidence interval, 0.059 to 0.829; p = 0.0253). The median total hospital charge was $30,800 (range, $20,400-$96,900) for 50 patients without prophylaxis and $26,700 (range, $11,000-$55,900) for 31 patients with prophylaxis (p = not significant). Patients receiving LDOA had lower accumulated charges per day of hospital stay (p = 0.0011). CONCLUSIONS: LDOA prophylaxis significantly reduces the incidence of atrial fibrillation after pulmonary resection. Its use in this population may be cost-effective. Results of this pilot study provide a rationale for a prospective randomized trial.