Usefulness of bicarbonate-based Impella purge solution in a patient with heparin-induced thrombocytopenia: the first case report of long-term management in Japan.

Percutaneous mechanical circulatory support utilizing micro-axial flow pumps, such as the Impella group of devices, has become a life-saving technique in the treatment of refractory cardiogenic shock, with ever-increasing success rates. A 30-year-old man presented with acute decompensated heart failure and a severely reduced left ventricular ejection fraction (17%). Despite initial treatment with inotropic drugs and intra-aortic balloon pump support, his hemodynamic status remained unstable. Transition to Impella CP mechanical circulatory support was made on day 6 owing to persistently low systolic blood pressure. A significant decline in platelet count prompted suspicion of heparin-induced thrombocytopenia (HIT), later confirmed by positive platelet-activated anti-platelet factor 4/heparin antibody and a 4Ts score of 6 points. Argatroban was initially used as the purge solution, but owing to complications, a switch to Impella 5.0 and a bicarbonate-based purge solution (BBPS) was performed. Despite additional veno-arterial extracorporeal membrane oxygenation support on day 24, the patient, aiming for ventricular assist device treatment and heart transplantation, died from infection and multiple organ failure. Remarkably, the Impella CP continued functioning normally until the patient's demise, indicating stable Impella pump performance using BBPS. This case highlights the usefulness of BBPS as an alternative to conventional Impella heparin purge solution when HIT occurs.

The incidence and influencing factors of in-hospital frailty progression following transcatheter aortic valve implantation.

Objective Patients undergoing transcatheter aortic valve implantation (TAVI) are generally older and frailty is therefore an important clinical issue. The baseline degree of frailty is associated with the prognosis in patients undergoing TAVI; however, the incidence of in-hospital frailty progression and its influencing factors have not yet been elucidated. Methods This observational, single-center study retrospectively evaluated 281 patients who underwent TAVI. The degree of frailty at baseline and discharge was evaluated using the Clinical Frailty Scale (CFS). In-hospital frailty progression was defined as an increase of at least one level in the CFS score at discharge from baseline, and predictors of frailty progression were assessed. Results The median baseline CFS score was 4.0 (interquartile range: 3.0-4.0). In-hospital frailty progression was observed in 49 patients (17.4%). No significant differences were observed in age, sex, comorbidities, or surgical risk scores between patients with and without frailty progression. Patients with frailty progression experienced stroke more frequently during hospitalization than those without (12.2% vs. 1.3%, p = 0.001). A multivariable logistic analysis showed that in-hospital stroke was a significant predictor of frailty progression (odds ratio, 10.7; 95% confidence interval: 2.34-49.2, p = 0.002). Patients with frailty progression had a longer hospital stay than those without frailty progression [7.0 (4.0-17.0) vs. 4.0 (4.0-8.0) days, p = 0.001]. Conclusions In-hospital frailty progression was not uncommon in patients undergoing TAVI. Stroke incidence was a significant influencing factor in frailty progression, whereas baseline comorbidities and surgical risks were not.

Patient management important for long-term support beyond 5 years in the BTT: republication of the article published in the Japanese Journal of Artificial Organs.

Heart transplantation is considered to be the best treatment for severe heart failure refractory to medical therapy, improving patients' survival and quality of life (QOL). However, the number of donors is smaller than the number of registered applicants for heart transplantation, which increases every year, and the waiting period for heart transplantation has been extended to more than 1700 days by 2022. Since 2011, reimbursement for the implantable left ventricular assist device (iLVAD) was established. The numbers of the iLVAD patients have been increasing year by year. Patients are managed at home with an iLVAD and can live with their families and even return to work, depending on the situation. On the other hand, self-management at home, including caregivers, is important for a safe life. Home management beyond 5 years is becoming more common due to long waiting time for transplant. This article outlines the important aspects of patient management for long-term support. This review was created based on a translation of the Japanese review written in the Japanese Journal of Artificial Organs in 2023 (Vol. 52, No. 1, pp. 62-66), with some modifications.

Thromboelastographic evaluation after cardiac surgery optimizes transfusion requirements in the intensive care unit: a single-center retrospective cohort study using an inverse probability weighting method.

OBJECTIVE: There are no reports from Japan showing the effects of using the thromboelastography algorithm on transfusion requirements after Intensive Care Unit (ICU) admission, and post-implementation knowledge regarding the thromboelastography algorithm under the Japanese healthcare system is insufficient. Therefore, this study aimed to clarify the effect of the TEG6s thromboelastography algorithm on transfusion requirements for patients in the ICU after cardiac surgery. METHODS: We retrospectively compared the requirements for blood transfusion up to 24 h after ICU admission using the thromboelastography algorithm (January 2021 to April 2022) (thromboelastography group; n = 201) and specialist consultation with surgeons and anesthesiologists (January 2018 to December 2020) (non-thromboelastography group; n = 494). RESULTS: There were no significant between-group differences in terms of age, height, weight, body mass index, operative procedure, duration of surgery or cardiopulmonary bypass, body temperature, or urine volume during surgical intervention. Moreover, there was no significant between-group difference in the amount of drainage at 24 h after ICU admission. However, crystalloid and urine volumes were significantly higher in the thromboelastography group than in the non-thromboelastography group. Additionally, fresh-frozen plasma (FFP) transfusion volumes were significantly lower in the thromboelastography group. However, there were no significant between-group differences in red blood cell count or platelet transfusion volume. After variable adjustment, the amount of FFP used from the operating room to 24 h after ICU admission was significantly reduced in the thromboelastography group. CONCLUSIONS: The thromboelastography algorithm optimized transfusion requirements at 24 h after admission to the ICU following cardiac surgery.

Impact of aortopulmonary collaterals on adverse events after total cavopulmonary connection.

OBJECTIVES: Effects of aortopulmonary collaterals (APCs) on outcomes after the total cavopulmonary connection (TCPC) are unclear. This study evaluated the incidence of APCs before and after TCPC and analysed the impacts of APCs on adverse outcomes. METHODS: A total of 585 patients, who underwent TCPC from 1994 to 2020 and whose preoperative angiographies were available, were included. Pre-TCPC angiograms in all patients were used for the detection of APCs, and post-TCPC angiograms were evaluated in selected patients. Late adverse events included late death, protein-losing enteropathy (PLE) and plastic bronchitis (PB). RESULTS: The median age at TCPC was 2.3 (1.8-3.4) years with a body weight of 12 (11-14) kg. APCs were found in 210 patients (36%) before TCPC and in 81 (14%) after TCPC. The closure of APCs was performed in 59 patients (10%) before TCPC, in 25 (4.2%) at TCPC and in 59 (10%) after TCPC. The occurrences of APCs before and after TCPC were not associated with short-term or mid-term mortality. The APCs before TCPC were associated with chylothorax (P = 0.025), prolonged chest tube duration (P = 0.021) and PB (P = 0.008). The APCs after TCPC were associated with PLE (P < 0.001) and PB (P < 0.001). With APCs following TCPC, freedom from PLE and PB was lower than without (P < 0.001, P < 0.001). CONCLUSIONS: APCs before TCPC were associated with chylothorax, prolonged chest tube duration and PB. APCs after TCPC were associated with both PLE and PB. The presence of APCs might affect the lymph drainage system and increase the incidence of chylothorax, PLE and PB.

[Perioperative Management of Coagulation After the Weaning of Cardiopulmonary Bypass in Cardiac Surgery].

During cardiopulmonary bypass, the major disturbances in coagulation systems were affected by perioperative hemo-dilutional changes. Dilutional coagulopathy which is usually followed by hemorrhage is often refractory at the end of cardiopulmonary bypass. Thus, perioperative monitoring of coagulation markers might be necessary to estimate the differential diagnosis of hemorrhage and decrease thrombotic complications. It is very important to understand the timely coagulation and hemolysis pattern after the weaning of cardiopulmonary bypass. There is a limitation of central laboratory test to get a real time perioperative hemostatic management. Point-of-care devices are increasingly applied in clinical practice as we used in our practice. The data from these devices are useful to establish optimal hemostatic strategies.

Development of novel waxy bone haemostatic agents composed of biodegradable polymers with osteogenic-enhancing peptides in rabbit models.

OBJECTIVES: The use of bone wax (BW) is controversial for sternal haemostasis because it increases the risk of wound infection and inhibits bone healing. We developed new waxy bone haemostatic agents made from biodegradable polymers containing peptides and evaluated them using rabbit models. METHODS: We designed 2 types of waxy bone haemostatic agents: peptide wax (PW) and non-peptide wax (NPW), which used poly(ε-caprolactone)-based biodegradable polymers with or without an osteogenesis-enhancing peptide, respectively. Rabbits were randomly divided into 4 groups based on treatment with BW, NPW, PW or no treatment. In a tibial defect model, the bleeding amount was measured and bone healing was evaluated by micro-computed tomography over 16 weeks. Bone healing in a median sternotomy model was assessed for 2 weeks using X-ray, micro-computed tomography, histological examination and flexural strength testing. RESULTS: The textures of PW and NPW (n = 12 each) were similar to that of BW and achieved a comparable degree of haemostasis. The crevice area of the sternal fracture line in the BW group was significantly larger than that in other groups (n = 10 each). The PW group demonstrated the strongest sternal flexural strength (n = 10), with complete tibial healing at 16 weeks. No groups exhibited wound infection, including osteomyelitis. CONCLUSIONS: Waxy biodegradable haemostatic agents showed satisfactory results in haemostasis and bone healing in rabbit models and may be an effective alternative to BW.

Cardiac rehabilitation in a heart-failure patient using customized "cardiac support net" treatment: a case report.

At our hospital, we are conducting the "Clinical Study of a Patient-Specific Cardiac Support Net for Dilated Cardiomyopathy (jRCTs042180025)", a multi-facility clinical study of a customized cardiac support net (CSN). Here, we describe the cardiac rehabilitation (CR) of a heart failure (HF) patient after CSN treatment. The patient was a 65-year-old man who exhibited dilated cardiomyopathy (DCM) because of left ventricular non-compaction; his New York Heart Association status was class III. In November 2019, he received CSN treatment. The early CR program was adapted for this patient, and his postoperative course was uneventful. Functional measurements showed improved leg-muscle strength (before treatment: 61.4% BW; at discharge: 77.3% BW). During long-term follow-up, the patient's exercise tolerance increased, as shown by 6-minute walk distance (before treatment: 576 m; long-term follow-up: 600 m) and peak oxygen uptake (before treatment: 12.5 mL/kg/min; long-term follow-up: 13.3 mL/kg/min). In the 2 years since discharge, the patient has not been hospitalized for HF. This report is the first to show that the CSN can be used to perform a CR program in a DCM patient without significant functional decline.

A review of current status of cell-based therapies for aortic aneurysms.

An aortic aneurysm (AA) is defined as focal aortic dilation that occurs mainly with older age and with chronic inflammation associated with atherosclerosis. The aneurysmal wall is a complex inflammatory environment characterized by endothelial dysfunction, macrophage activation, vascular smooth muscle cell (VSMC) apoptosis, and the production of proinflammatory molecules and matrix metalloproteases (MMPs) secreted by infiltrated inflammatory cells such as macrophages, T and B cells, dendritic cells, neutrophils, mast cells, and natural killer cells. To date, a considerable number of studies have been conducted on stem cell research, and growing evidence indicates that inflammation and tissue repair can be controlled through the functions of stem/progenitor cells. This review summarizes current cell-based therapies for AA, involving mesenchymal stem cells, VSMCs, multilineage-differentiating stress-enduring cells, and anti-inflammatory M2 macrophages. These cells produce beneficial outcomes in AA treatment by modulating the inflammatory environment, including decreasing the activity of proinflammatory molecules and MMPs, increasing anti-inflammatory molecules, modulating VSMC phenotypes, and preserving elastin. This article also describes detailed studies on pathophysiological mechanisms and the current progress of clinical trials.

Incidence and clinical impact of silent pancreatitis after aortic arch surgery.

BACKGROUND: This study was designed to investigate the incidence and types of pancreatic injury, risk factors, and time-course changes in computed tomographic findings following total aortic arch replacement with moderate hypothermic circulatory arrest. METHODS: Medical records of patients who underwent total arch replacement between January 2006 and August 2021 were retrospectively reviewed. A comparison study between the patients with (group P) and without pancreatic injury (group N) was conducted to elucidate the impact of pancreatic injury. Follow-up computed tomography of the patients in group P was reviewed to investigate time-course changes of the pancreatic injury. RESULTS: Of 353 patients, 14 (4.0%) had subclinical pancreatic injury. Computed tomographic findings were consistent with acute pancreatitis in all patients, of whom eight patients had interstitial edematous pancreatitis, whereas six patients had necrotizing pancreatitis. Although walled-off necrosis occurred in three patients, none of them required drainage. In-hospital mortality was 7.1% and 4.4% in groups P and N, respectively (p = 0.98). The 5-year actuarial survival rates were 77.9% and 81.0% in groups P and N, respectively (p = 0.51). Multivariate analysis revealed that pancreatic injury was associated with chronic obstructive pulmonary disease (p = 0.03). CONCLUSIONS: This study highlighted that silent pancreatic injury after aortic arch surgery is underrecognized. Potential arterial sclerosis of the pancreatic circulation seems to be related to pancreatic injury.

Contractile pericarditis-like hemodynamics in dilated-phase hypertrophic cardiomyopathy with giant atrium.

A 47-year-old man with dilated-phase hypertrophic cardiomyopathy was admitted to the hospital with worsening heart failure. As the enlarged atrium caused a constrictive pericarditis-like hemodynamic condition, atrial wall resection and tricuspid valvuloplasty were performed. Postoperatively, pulmonary artery pressure rose due to increased preload; however, the rise in pulmonary artery wedge pressure was restrained, and the cardiac output significantly improved. When the pericardium is extremely stretched due to atrial enlargement, it can lead to an elevation of intrapericardial pressure, and both atrial volume reduction and tricuspid valve plasty could lead to increased compliance and contribute to hemodynamic improvement. Learning objective: Atrial wall resection for massive atrial enlargement and tricuspid annuloplasty in patients with diastolic-phase hypertrophic cardiomyopathy effectively relieves unstable hemodynamics.

Cardiac Rehabilitation in Severe Heart Failure Patients with Impella 5.0 Support via the Subclavian Artery Approach Prior to Left Ventricular Assist Device Implantation.

Impella 5.0 circulatory support via subclavian artery (SA) access may be a safe approach for patients undergoing cardiac rehabilitation (CR). In this case series, we retrospectively analyzed the demographic characteristics, physical function, and CR data of six patients who underwent Impella 5.0 implantation via the SA prior to left ventricular assist device (LVAD) implantation between October 2013 and June 2021. The median age was 48 years, and one patient was female. Grip strength was maintained or increased in all patients before LVAD implantation (pre-LVAD) compared to after Impella 5.0 implantation. The pre-LVAD knee extension isometric strength (KEIS) was less than 0.46 kgf/kg in two patients and more than 0.46 kgf/kg in three patients (unavailable KEIS data, n = 1). With Impella 5.0 implantation, two patients could ambulate, one could stand, two could sit on the edge of the bed, and one remained in bed. One patient lost consciousness during CR due to decreased Impella flow. There were no other serious adverse events. Impella 5.0 implantation via the SA allows mobilization, including ambulation, prior to LVAD implantation, and CR can be performed relatively safely.

Clinical implications of the cardio-ankle vascular index before and after transcatheter aortic valve implantation.

BACKGROUND: Arterial stiffness indices are used to assess the material properties of the arterial wall and are associated with cardiovascular events. Aortic stenosis (AS) is commonly caused by degenerative calcification and can be associated with increased arterial stiffness. However, the clinical implications of arterial stiffness indices in AS patients before and after treatment are unknown. METHODS: This single-center observational study enrolled 150 consecutive patients who underwent transcatheter aortic valve implantation (TAVI) for severe AS. The cardio-ankle vascular index (CAVI) was measured before and after TAVI. The patients were divided into two groups according to the CAVI values before and after TAVI: high CAVI group and low CAVI group. Patient and echocardiographic data and clinical outcomes, including cardiac death and hospitalization for heart failure (HF), were compared. RESULTS: The pre- and postprocedural CAVI was 7.90 (6.75-9.30) and 9.65 (8.90-10.65), respectively. In the analyses with preprocedural CAVI, preprocedural echocardiographic aortic valve peak flow velocity was significantly lower in the high CAVI group. No significant differences between the two groups were observed in the occurrence of cardiac death or hospitalization for HF. In the analyses with postprocedural CAVI, B-type natriuretic peptide levels and E / e ' ratio after TAVI were significantly higher in the high CAVI group. The composite of cardiac death and hospitalization occurrence for HF was significantly higher in the high CAVI group. CONCLUSION: CAVI before TAVI is mainly affected by the AS severity, while CAVI after TAVI is associated with left ventricular diastolic dysfunction and late cardiac events, which may reflect arterial stiffness.

Administration of anti-inflammatory M2 macrophages suppresses progression of angiotensin II-induced aortic aneurysm in mice.

Aortic aneurysm (AA) is a vascular disorder characterized pathologically by inflammatory cell invasion and extracellular matrix (ECM) degradation. It is known that regulation of the balance between pro-inflammatory M1 macrophages (M1Ms) and anti-inflammatory M2 macrophages (M2Ms) plays a pivotal role in AA stabilization. We investigated the effects of M2M administration in an apolipoprotein E-deficient (apoE-/-) mouse model in which AA was induced by angiotensin II (ATII) infusion. Mice received intraperitoneal administration of 1 million M2Ms 4 weeks after ATII infusion. Compared with a control group that was administered saline, the M2M group exhibited reduced AA expansion; decreased expression levels of interleukin (IL)-1ß, IL-6, tumor necrosis factor-α (TNF-α), and monocyte chemoattractant protein-1 (MCP-1); and a lower M1M/M2M ratio. Moreover, the M2M group exhibited upregulation of anti-inflammatory factors, including IL-4 and IL-10. PKH26-labeled M2Ms accounted for 6.5% of cells in the aneurysmal site and co-expressed CD206. Taken together, intraperitoneal administration of M2Ms inhibited AA expansion by reducing the inflammatory reaction via regulating the M1M/M2M ratio. This study shows that M2M administration might be useful for the treatment of AA.

Increased risk of purge system malfunction after Impella 5.0 replacement: a case series.

The Impella 5.0 is an axial-flow percutaneous ventricular assist device used in patients with cardiogenic shock. Although the recommended period of use is 10 days or less, weaning can be delayed because of ongoing hemodynamic instability. In clinical practice, this device sometimes malfunctions during long-term management with heparin and must be replaced; however, the relationship between the duration of support with the initial and replacement Impella 5.0 and the changes in value of the purge system has not been fully elucidated. From July 2018 to May 2021, Impella 5.0 was implanted and used for more than 10 days in 11 patients at our institution. Four patients required Impella replacement because of device malfunction and the second Impella had purge system malfunction in all cases. The second Impella was used for a significantly shorter time than the first Impella (p = 0016). We calculated the ratio of purge pressure to purge flow rate and found that the ratio exceeded 50 mm Hg/mL/h in all cases with purge system malfunction. In conclusion, it is important to construct a treatment strategy considering the duration of use, because the risk of purge system malfunction is high after replaced Impella 5.0.

Factors associated with postsurgical muscle weakness in patients who undergo thoracic aortic surgery: a retrospective cohort study.

OBJECTIVE: Aortic surgery is often performed in elderly patients, and these patients have a high risk of postsurgical muscle weakness. To reinforce purposeful postsurgical rehabilitation, we aimed to investigate the factors associated with postsurgical muscle weakness in patients who underwent thoracic aortic surgery. METHODS: This retrospective cohort study analyzed data of consecutive patients who underwent elective thoracic aortic surgery with cardiopulmonary bypass, and whose knee extensor isometric muscle strength (KEIS) were measured pre- and postoperatively at University Hospital between January 2012 and December 2018. The primary outcome was percent change in KEIS (% change in KEIS). Multivariate linear regression analysis was used to identify independent risk factors for % change in KEIS. RESULTS: Overall, 218 patients were included. Multivariate linear regression analysis showed that mechanical ventilation time, days from initial sitting to 100 m walking, and the number of exercises in the rehabilitation room were associated with % change in KEIS. CONCLUSIONS: This study may serve as a reference to stratify patients at risk of postsurgical muscle weakness. The preventive or alternative interventions in patients undergoing thoracic aortic surgery will be assessed in future studies.