Left Atrial Veno-Arterial Extracorporeal Membrane Oxygenation Case Series: A Single-Center Experience.

INTRODUCTION: We aimed to review the characteristics and outcomes of left atrial veno-arterial extra corporeal membrane oxygenation (LAVA ECMO) at our institution over a 4-y period from 2017 to 2020. METHODS: Among 227 adult patients who received VA ECMO support from January 2017 to December 2020, we reviewed 33 of these who underwent transseptal cannulation and were converted to LAVA ECMO. The timing of transseptal cannulation, either at initiation of VA ECMO (n = 25) or with a later transseptal cannulation to treat complications of left ventricular (LV) distention while on VA ECMO (n = 8), was reviewed. The clinical characteristics, indications, echocardiography data, and outcomes were assessed. RESULTS: Duration of LAVA ECMO support ranged from 1 to 13 d, with a median of 5 d. Successful weaning from the LAVA ECMO circuit was achieved for 15 patients (45%). The in-hospital mortality rate was 66%. There were 11 patients (33%) who survived to be discharged from the hospital. CONCLUSIONS: LV distention is a known complication of VA ECMO and impedes the recovery of the heart. LAVA ECMO provides a novel approach to treating LV distention. Additionally, our review shows that this modality may be used as a bridge to durable mechanical circulatory support, cardiac transplantation, or recovery.

Cannula migration through an undiagnosed patent foramen ovale and embolic cerebrovascular accident in a patient with femoral venoarterial extracorporeal membrane oxygenation.

We present a case report of a patient with a pulmonary embolus placed on venoarterial extracorporeal membrane oxygenation who developed venous cannula migration through an undiagnosed patent foramen ovale causing an ischemic stroke due to a thrombus and requiring thrombectomy and device closure of the atrial defect.

Emergent percutaneous therapy for left ventricular assist device retrograde flow.

With the number of heart transplants being performed each year stagnating due to lack of donors the left ventricular assist device (LVAD) patient population will continue to grow. As more and more patients are living longer with LVADs, either as a bridge to transplant or destination therapy, we will continue to see an increased number of complications related to assist device therapy. One of the common challenges physicians face are patients who suffer from both bleeding and thrombotic complications. When bleeding complications occur anticoagulation is usually reduced or discontinued and then the thrombosis risk increases. Once a pump thrombosis occurs there are limited percutaneous treatment strategies available, especially in the setting of a recent bleeding event. Surgical exchange is the only definitive therapy and that can be a high risk and difficult operation. Turning off an LVAD may become necessary, as it did in our case, but that can lead to significant retrograde flow through the device and rapid patient decline. A prompt percutaneous therapy is needed to stabilize these patients.

Single incision technique for implantation of subcutaneous implantable cardioverter defibrillators.

BACKGROUND: Subcutaneous implantable cardioverter defibrillators (S-ICDs) have gained increasing popularity because of certain advantages over transvenous ICDs. However, while conventional ICDs require a single surgical incision to implant, S-ICDS need two or three incisions, making them less appealing. OBJECTIVE: This study sought out to investigate the feasibility of using a single-incision technique to implant S-ICDs. METHODS: Patients qualifying for S-ICDs were considered for a single incision. A single incision is performed by making a left inframammary incision and then the subcutaneous tissue is dissected medially toward the lower sternum. Two sutures are placed in the fascia in the xiphoid area to anchor the lead and a tunneling tool is used to dissect the tissue to place the lead parallel to the sternum. Then subcutaneous tissues are dissected down the lateral chest wall over the muscle fascia to create the pulse generator pocket in the vicinity of the fifth and sixth intercostal spaces and near the mid-axillary line. RESULTS: Eleven patients (six males and five females) successfully underwent S-ICD implantation with a single incision without acute complications (64% for primary prevention). The mean age is 47.4 ± 15.8 years. There were no lead dislodgements, inappropriate shocks, or any other issues during a median follow-up of 10 months (interquartile range 5-17). One patient had a successful appropriate shock for ventricular fibrillation about one year after device implant. CONCLUSIONS: A single incision for subcutaneous ICDs is feasible and safe in our early experience.

Use of AngioVac for Removal of Tricuspid Valve Vegetation.

The use is reported of the AngioVac system to resolve a case of persistent bacteremia in the setting of MRSA tricuspid valve infective endocarditis. The infection was secondary to intravenous drug use in a patient who had failed multiple antibiotic regimens and was deemed a poor surgical candidate.

A novel approach to percutaneous removal of large tricuspid valve vegetations using suction filtration and veno-venous bypass: A single center experience.

BACKGROUND: Tricuspid valve surgery has been the de facto standard treatment for tricuspid valve endocarditis (TVE) refractory to medical therapy. It is now possible to remove right-sided vegetations percutaneously using a venous drainage cannula with an extracorporeal bypass circuit. OBJECTIVES: The purpose of our study is to describe our single-center experience of percutaneous tricuspid valve vegetation removal. METHODS: We reviewed the perioperative course of 33 consecutive patients with large tricuspid valve vegetations who carried high surgical risk. RESULTS: The cohort included 12 males and 21 females over a 40-month period with an average age of 37 years. A preponderance of patients carried an admitted or confirmed diagnosis of injection drug use (72.7%). Average vegetation size was 2.1 +/- 0.7 cm prior to the procedure with a 61% reduction in size after the procedure. All patients survived the procedure and 90.9% survived the index hospitalization. Three patients proceeded to elective tricuspid valve replacement due to worsening severity of tricuspid regurgitation. CONCLUSION: Percutaneous removal of large tricuspid valve vegetations is a safe and effective alternative for patients with TVE who carry high-surgical risk. © 2017 Wiley Periodicals, Inc.

Use of Cardioplegia to Guide Alcohol Ablation for Incessant Ventricular Tachycardia.

Incessant scar-related reentrant ventricular tachycardia is an important cause of morbidity and mortality. In patients not amenable to emergent radiofrequency catheter ablation, selective transcoronary alcohol ablation has been successfully performed. In our case study, we introduce the novel use of cardioplegia as a mapping technique for identification of the critical ventricular tachycardia isthmus to guide efficient transcoronary alcohol ablation and prevent unnecessary myocardial damage.

Acute Effects of Implantable Cardioverter-Defibrillator Shocks on Biomarkers of Myocardial Injury, Apoptosis, Heart Failure, and Systemic Inflammation.

BACKGROUND: Implantable cardioverter-defibrillator (ICD) shocks are potentially associated with myocardial injury, altered hemodynamics, apoptosis, and inflammatory signaling. Their precise cellular impact can be explored after defibrillation testing (DFT) via biomarkers. We evaluated changes in biomarkers after ICD shocks during DFT. METHODS: We prospectively enrolled outpatients presenting for first implantation of a cardiac device. Biomarkers indicative of myocardial injury, inflammation, and apoptosis were measured before and after implantation, and compared between patients receiving DFT (DFT+) to those not (DFT-). RESULTS: Sixty-three patients were enrolled, 40 in the DFT+ group and 23 in the DFT- group. Average levels of troponin I, hsCRP, Calprotectin, N-terminal pro B-type natriuretic peptide (NTproBNP), and sFas increased by >50% after cardiac device implantation compared to baseline. Increase in troponin never exceeded the 50-fold upper limit of normal (2 ng/mL). Troponin trended higher in the DFT+ group at 8 hours (median 0.18 ng/mL, interquartile range [IQR] 0.11-0.48) versus the DFT- group (0.10 ng/mL, IQR 0.06-0.28, P = 0.0501); NTproBNP had a similar trend (P = 0.0581). sFas significantly increased in the DFT+ group from baseline (median 4663 pg/mL, IQR 2908-5679) to 24 hours (5039 pg/mL, IQR 3274-6261; P = 0.0338) but not in the DFT- group (P = 0.4705). CONCLUSION: DFT testing is associated with acutely increased plasma levels of troponin and sFas, a biomarker of apoptosis, along with a trend toward higher NTproBNP.

Predictors, Morbidity, and Costs Associated with Pneumothorax during Electronic Cardiac Device Implantation.

BACKGROUND: Pneumothorax (PTX) is a major cause of morbidity associated with cardiac implantable electronic devices (CIEDs). We sought to evaluate predictors of PTX at our centers during CIED implantations, including the venous access technique utilized, as well as to determine morbidity and costs associated with PTX. METHODS: We reviewed records of all patients undergoing cardiac device implant or revision with new venous access at our institutions between 2008 and 2014. Common demographic and procedure characteristics were collected including age, sex, body mass index (BMI), comorbidities, and method of venous access (axillary vein vs classic proximal subclavian vein technique). RESULTS: We identified 1,264 patients who met criteria for our analysis, with a total of 21 PTX cases during CIED implantation. The strongest predictor for PTX was the venous access strategy: 0 of 385 (0%) patients with axillary vein approach versus 21 of 879 (2.4%) with traditional subclavian vein approach, P = 0.0006. Additional predictors of PTX included advanced age, female sex, low BMI, and a new device implant (vs device upgrade). The occurrence of PTX was associated with increased length of stay: 3.0 days (median; interquartile range [IQR] 3) versus 1.0 day (median; IQR: 1), P = 0.0001, with a cost increase of 361.4%. CONCLUSION: An axillary vein vascular access strategy was associated with greatly reduced risk of iatrogenic PTX versus the traditional subclavian approach for CIED placement. Similarly, device upgrade with patent vascular access carried less risk of PTX compared to new device implantation. PTX occurrence significantly prolonged hospitalization and increased costs.

Thromboinflammatory response and predictors of outcomes in patients undergoing transcatheter aortic valve replacement.

Transcatheter aortic valve replacement (TAVR) has been increasingly used to treat patients with symptomatic aortic stenosis. Despite improvements in valve deployment, patients that have undergone TAVR are at high risk for major adverse events following the procedure. Blood cell numbers, platelet function, and biomarkers of systemic inflammation were analyzed in 58 patients undergoing TAVR with the Edward's SAPIEN valve. Following valve deployment, platelet count and agonist-induced platelet activity declined and plasma markers of systemic inflammation (interleukin-6 and S100A8/A9) increased. Baseline platelet activity prior to TAVR correlated with perioperative changes plasma interleukin-6 levels. Moreover, perioperative changes in plasma inflammatory markers predicted the decline in platelet count in the days following the TAVR procedure. Additionally, a significant effect of gender on platelet count following TAVR and was observed. Finally, post-procedural mortality was associated with sustained thrombocytopenia after TAVR. Our findings suggest that TAVR elicits a thromboinflammatory state that may contribute to post-procedural thrombocytopenia. Importantly, our results add to the growing body of literature that suggests the thromboinflammatory changes that occur early after TAVR may predict long-term outcomes.

A retrospective analysis of catheter-based thrombolytic therapy for acute submassive and massive pulmonary embolism.

Catheter-based thrombolysis (CBT) is emerging as an option for acute pulmonary embolism (PE). Although prior studies have demonstrated improvement in right ventricular function, little data is available regarding clinical patient outcomes. Our institution adopted CBT as an option for patients with submassive and massive PE and we evaluated its effect on patient outcomes. Two hundred and twenty-one patients who presented to our institution with submassive and massive PE were analyzed over three years by time period; 102 prior to the use of CBT and 119 during the time CBT was performed. The primary outcome was in-hospital major adverse clinical events (a composite of death, recurrent embolism, major bleeding, or stroke). Secondary outcomes were overall and ICU length of stay and individual components of the composite outcome. Mean age was 56.3±16 years with high rates of central PE (57.9%), RV dysfunction (37%), and myocardial necrosis (26%). Mean RV/LV ratio was 1.2. Thirty-two patients were treated with CBT. The composite endpoint occurred more frequently in the CBT era vs the pre-CBT era (21.0% vs 14.7%, p=0.23). After multivariate adjustment, CBT treatment demonstrated no effect on major adverse clinical events (OR 0.84, CI 0.22-3.22, p=0.80). CBT era patients had an unadjusted 37% increase in ICU days and 54% increase in total length of stay (p<0.001). Within the CBT era, CBT treatment resulted in an adjusted 190% increase in overall length of stay (p<0.001). CBT did not demonstrate improvement in hospital outcomes, despite adjustments of PE severity, and was associated with a significant increase in overall and ICU length of stay.

QRS duration predicts death and hospitalization among patients with atrial fibrillation irrespective of heart failure: evidence from the AFFIRM study.

AIMS: The association of QRS duration (QRSd) with morbidity and mortality is understudied in patients with atrial fibrillation (AF). We sought to assess any association of prolonged QRS with increased risk of death or hospitalization among patients with AF. METHODS AND RESULTS: QRS duration was retrieved from the baseline electrocardiograms of patients enroled in the Atrial Fibrillation Follow-Up Investigation of Rhythm Management (AFFIRM) study and divided into three categories: <90, 90-119, ≥120 ms. Cox models were applied relating the hazards of mortality and hospitalizations to QRSd. Among 3804 patients with AF, 593 died and 2305 were hospitalized. Compared with those with QRS < 90 ms, patients with QRS ≥ 120 ms, had an increased mortality [hazard ratio (HR) 1.61, 95% confidence interval (CI): 1.29-2.03, P < 0.001] and hospitalizations (HR 1.14, 95% CI: 1.07-1.34, P = 0.043) over an average follow-up of 3.5 years. Importantly, for patients with QRS 90-119 ms, mortality and hospitalization were also increased (HR 1.31, P = 0.005 and 1.11, P = 0.026, respectively). In subgroup analysis based on heart failure (HF) status (previously documented or ejection fraction <40%), mortality was increased for QRS ≥ 120 ms patients with (HR 1.87, P < 0.001) and without HF (HR 1.63, P = 0.02). In the QRS 90-119 ms group, mortality was increased (HR 1.38, P = 0.03) for those with HF, but not significantly among those without HF (HR 1.23, P = 0.14). CONCLUSION: Among patients with AF, QRSd ≥ 120 ms was associated with a substantially increased risk for mortality (all-cause, cardiovascular, and arrhythmic) and hospitalization. Interestingly, an increased mortality was also observed among those with QRS 90-119 ms and concomitant HF.

Increased mortality among patients taking digoxin--analysis from the AFFIRM study.

AIMS: Digoxin is frequently used for rate control of atrial fibrillation (AF). It has, however, been associated with increased mortality. It remains unclear whether digoxin itself is responsible for the increased mortality (toxic drug effect) or whether it is prescribed to sicker patients with inherently higher mortality due to comorbidities. The goal of our study was to determine the relationship between digoxin and mortality in patients with AF. METHODS AND RESULTS: The association between digoxin and mortality was assessed in patients enrolled in the AF Follow-Up Investigation of Rhythm Management (AFFIRM) trial using multivariate Cox proportional hazards models. Analyses were conducted in all patients and in subsets according to the presence or absence of heart failure (HF), as defined by a history of HF and/or an ejection fraction <40%. Digoxin was associated with an increase in all-cause mortality [estimated hazard ratio (EHR) 1.41, 95% confidence interval (CI) 1.19-1.67, P < 0.001], cardiovascular mortality (EHR 1.35, 95% CI 1.06-1.71, P = 0.016), and arrhythmic mortality (EHR 1.61, 95% CI 1.12-2.30, P = 0.009). The all-cause mortality was increased with digoxin in patients without or with HF (EHR 1.37, 95% CI 1.05-1.79, P = 0.019 and EHR 1.41, 95% CI 1.09-1.84, P = 0.010, respectively). There was no significant digoxin-gender interaction for all-cause (P = 0.70) or cardiovascular (P = 0.95) mortality. CONCLUSION: Digoxin was associated with a significant increase in all-cause mortality in patients with AF after correcting for clinical characteristics and comorbidities, regardless of gender or of the presence or absence of HF. These findings call into question the widespread use of digoxin in patients with AF.

Beyond a team: The comprehensive interdisciplinary endocarditis program in the United States.

Although multidisciplinary teams have been shown to decrease in-hospital mortality for patient with infectious endocarditis, most studies have focused on the inpatient role of these teams, and are primarily based at European tertiary care centers. There is limited literature available on the optimal longitudinal care of this patient population. Here we outline our experience developing an interdisciplinary endocarditis program at the University of Kentucky, which cares for patients from their index hospitalization into the outpatient setting, while also coordinating transfers from regional hospitals and offering education to regional providers.

Septal perforator anatomy and variability of perfusion bed by myocardial contrast echocardiography: a study of hypertrophic cardiomyopathy patients undergoing alcohol septal ablation.

OBJECTIVE: To characterize the perfusion bed of the first septal perforator by myocardial contrast echocardiography (MCE) in patients with hypertrophic cardiomyopathy undergoing alcohol septal ablation (ASA). BACKGROUND: MCE is used to define the septal perforator anatomy prior to ASA. Occasionally, ASA cannot be performed due to unfavorable septal anatomy or perfusion outside the interventricular septum. Despite the standard use of MCE for septal mapping, there are no reports describing the territory of septal perforator perfusion. METHODS: Forty-seven consecutive patients underwent ASA between 1/1/2004 and 12/30/2012. Blinded individuals retrospectively evaluated patients for septal perforator anatomic findings. Patients were divided into 2 groups based on presence or absence of extra-septal perfusion (ESP) as visualized by apical views after intracoronary contrast injection. The groups' procedural outcomes were compared, including infarct size, new conduction abnormalities, and major adverse events. RESULTS: Over 25% demonstrated ESP, of which 83% predominantly involved the right ventricular (RV) moderator band. The first septal perforator (FSP) was statistically larger in ostial diameter (1.69 mm vs. 1.23 mm, P = 0.04) and numerically more likely dominant in patients with ESP (63.6% vs. 47.2%, P = 0.22). In those with ESP, the odds ratio comparing FSP diameter of 2.0 mm to the mean was 1.96 (95% CI: 1.01-3.80). CONCLUSIONS: Downstream capillary perfusion may be discordant from epicardial territory and this study emphasizes the importance of MCE prior to ASA. Over 25% of our patients demonstrated ESP, most commonly involving the RV moderator band. The size of the FSP was the strongest predictor of ESP.

Balloon-facilitated delivery of a left ventricular pacing lead.

While modern implant tools have contributed greatly to the success of cardiac resynchronization therapy, technical challenges remain. A common problem is the inability to advance left ventricular pacing leads into branch veins that are tortuous or arise at steep angles. In these cases, advancement of the lead causes it to buckle and prolapse into the coronary sinus or great cardiac vein. Lead prolapsed can be avoided by employing a balloon to temporarily obstruct the coronary sinus or great cardiac vein just upstream from the branch vein. The balloon redirects the force of advancement laterally into the branch vein, facilitating delivery.

Diffuse Coronary Vasospasm After Mitral Valve Replacement, Maze Procedure, and Tricuspid Valve Repair.

Coronary vasospasm is a known complication after coronary artery bypass grafting surgery but has rarely been described in non-coronary cardiac operations. We report the case of a 51-year-old male with nonischemic cardiomyopathy and paroxysmal atrial fibrillation. He presented with severe mitral and tricuspid regurgitation and was taken for mitral valve replacement, tricuspid valve repair, and Maze procedure. Postoperative emergent coronary angiography demonstrated diffuse coronary vasospasm. Injection of intracoronary nitroglycerin led to clinical and angiographic improvement. This demonstrates the possibility of coronary vasospasm following mitral valve replacement and effective treatment with intracoronary administration of vasodilating agents.

The inside-out technique is safe and effective for thoracic central venous obstruction.

BACKGROUND: Thoracic central venous obstruction (TCVO) presents a challenging scenario for patients requiring central venous access. The inside-out technique for crossing occluded veins has been described; however, to date, case series have reported on a limited number of patients. The purpose of the present study was to evaluate the indications for, efficacy of, and outcomes with the inside-out technique at a single tertiary academic center, with close attention to the severity of TCVO using the Society of Interventional Radiology (SIR) TCVO classification. METHODS: Patients who had undergone central venous access using the inside-out technique were identified from August 2007 to May 2021. The patient demographics, procedure indication, procedural details, SIR TCVO classification, outcomes, and procedure-related complications were recorded. Statistical analysis was performed using analysis of variance. RESULTS: A total of 221 patients (109 men [49.3%] and 112 women [50.6%]) had undergone 338 inside-out procedures. Of the 221 patients, 49 had undergone the procedure multiple times (25 two times, 11 three times, 13 more than three times). The average patient age was 54.7 ± 14.8 years. The indications (n = 362) for the procedure included dialysis access (n = 230; 63.5%), infusion of parenteral nutrition, antibiotics, chemotherapy, or other medication (n = 81; 22.3%), cardiac access (n = 39; 10.8%), and other (n = 12; 3.3%); more than one indication for 20 procedures. Type 1 SIR TCVO was found during 147 procedures (43.5%), followed by type 4 for 142 (42.0%), type 2 for 36 (10.7%), type 3 for 6 (1.8%), and unable to determine for 7 (2.0%). The access site was the right femoral vein for 322 procedures (95.3%), left femoral vein for 14 (4.1%), and transhepatically for 2 (0.6%). The exit site location was the right supraclavicular region for 274 (81.3%), right subclavicular for 52 (15.4%), left supraclavicular for 3 (0.9%), left subclavicular for 6 (1.8%), and not defined for 2 (0.6%). Types 3 and 4 were associated with longer fluoroscopy times and more contrast compared with types 1 and 2. The median follow-up and device duration was 56.0 days and 76.5 days, respectively. No differences were found in device duration between the SIR TCVO types. Removal of a catheter was documented for 166 patients. The indications for removal included infectious causes (non-catheter-related bacteremia, catheter-related infection or bacteremia) for 70 (42.1%), catheter malfunction for 34 (20.5%), new hemodialysis access for 19 (11.5%), no longer needed for 19 (11.5%), patient removal of the catheter by 13 (7.8%), and replacement of a temporary catheter with a tunneled device for 11 (6.6%). No procedural complications were associated with the inside-out technique or catheter removal. CONCLUSIONS: For a variety of indications, we have shown that the inside-out technique is safe and effective for establishing central venous access in patients with TCVO and can be performed repeatedly. More complex obstructive patterns were associated with longer fluoroscopy times and greater contrast administration. Durability was primarily limited by infectious complications.

Ratio of Mixed Venous Oxygen Saturation-to-Pulmonary Capillary Wedge Pressure: Insights From the Veterans Affairs Clinical Assessment, Reporting, and Tracking Program.

BACKGROUND: Hemodynamic values from right heart catheterization aid diagnosis and clinical decision-making but may not predict outcomes. Mixed venous oxygen saturation percentage and pulmonary capillary wedge pressure relate to cardiac output and congestion, respectively. We theorized that a novel, simple ratio of these measurements could estimate cardiovascular prognosis. METHODS: We queried Veterans Affairs' databases for clinical, hemodynamic, and outcome data. Using the index right heart catheterization between 2010 and 2016, we calculated the ratio of mixed venous oxygen saturation-to-pulmonary capillary wedge pressure, termed ratio of saturation-to-wedge (RSW). The primary outcome was time to all-cause mortality; secondary outcome was 1-year urgent heart failure presentation. Patients were stratified into quartiles of RSW, Fick cardiac index (CI), thermodilution CI, and pulmonary capillary wedge pressure alone. Kaplan-Meier curves and Cox proportional hazards models related comparators with outcomes. RESULTS: Of 12 019 patients meeting inclusion criteria, 9826 had values to calculate RSW (median 4.00, interquartile range, 2.67-6.05). Kaplan-Meier curves showed early, sustained separation by RSW strata. Cox modeling estimated that increasing RSW by 50% decreases mortality hazard by 19% (estimated hazard ratio, 0.81 [95% CI, 0.79-0.83], P<0.001) and secondary outcome hazard by 28% (hazard ratio, 0.72 [95% CI, 0.70-0.74], P<0.001). Among the 3793 patients with data for all comparators, Cox models showed RSW best associated with outcomes (by both C statistics and Bayes factors). Furthermore, pulmonary capillary wedge pressure was superior to thermodilution CI and Fick CI. Multivariable adjustment attenuated without eliminating the association of RSW with outcomes. CONCLUSIONS: In a large national database, RSW was superior to conventional right heart catheterization indices at assessing risk of mortality and urgent heart failure presentation. This simple calculation with routine data may contribute to clinical decision-making in this population.