[Successful Use of Left Ventricular Support Device (Impella 5.0) for Ischemic Heart Disease with Cardiogenic Shock:Report of a Case].

Postoperative hemodynamic support with an Impella 5.0 was effective in an obese man who underwent coronary artery bypass grafting (CABG) for ischemic heart disease and cardiogenic shock. A 43-year-old obese man presented to our hospital complaining severe chest pain. Coronary angiography revealed acute coronary syndrome due to severe triple-vessel disease, and the patient fell into a state of shock, which required veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. The patient subsequently underwent CABG, but he was unable to be separated from VA-ECMO. Impella 5.0 was introduced through right axillary artery on the next day. VA-ECMO was converted to veno-venous (VV)-ECMO on the 3rd postoperative day to enable respiratory rehabilitation in a sitting posi-tion;his respiratory status gradually improved. VV-ECMO and the Impella 5.0 were discontinued on the 6th and 7th postoperative days, respectively. He was eventually transferred to nearby facility for further rehabilitation three months later. As of two years, his cardiac function has improved and he is doing well at home.

[Isolated Pulmonary Valve Endocarditis Accompanying Multiple Pulmonary Embolisms:Report of a Case].

Isolated pulmonary valve infective endocarditis is rare and accounts for only 1.5% to 2.0% of all cases of infective endocarditis. We present a case of isolated pulmonary valve endocarditis, which was successfully treated by pulmonary valve replacement. A 69-year-old man presented with fever and was diagnosed with active pulmonary valve infective endocarditis. He had no apparent predisposing factors. Blood cultures were positive for Streptococcus viridans, and transesophageal echocardiography showed mobile vegetation. His condition improved transiently with intravenous antibiotic therapy;however, high fever and reduced oxygen saturation recurred. Computed tomography showed multiple infiltrative shadows suggesting septic pulmonary embolisms. Urgent surgery was indicated because antibiotic treatment was ineffective. During the operation, we found that vegetation had destroyed all pulmonary leaflets. We performed pulmonary valve replacement with a stented bioprosthetic valve as well as enlargement of the right ventricular outflow tract with a bovine pericardial patch. The postoperative course was uneventful. Antibiotic therapy was continued for six weeks after surgery. For two years since surgery, the patient has experienced no recurrence of infection.

[Cardiac Amyloidosis Diagnosed Following Mitral Valve Repair; Report of a Case].

We present a case of a 60-year-old female who underwent elective mitral valve repair for mitral valve regurgitation. Intra-aortic balloon pumping was necessary to wean her from cardiopulmonary bypass, and a sudden cardiac arrest happened on postoperative day 17. Due to such unexpected postoperative course, a right ventricular biopsy was done, and she was diagnosed with light chain amyloidosis (AL) type cardiac amyloidosis. Despite long percutaneous cardiopulmonary bypass support, she never recovered from severe heart failure. Cardiac surgeons should be aware of this fatal disease, and preoperative screening with various tests is required.

Short-term in vivo performance of the Cleveland clinic PediPump left ventricular assist device.

The PediPump was implanted in six healthy lambs (mean 25.6 ± 1.4 kg) between the left ventricular apex and the descending aorta to evaluate in vivo performance for up to 30 days. Anticoagulation was achieved by continuous heparin infusion. Three animals were euthanized prematurely, two because of respiratory dysfunction and one because of deteriorating pump performance resulting from thrombus formation inside the pump. Three lambs were electively sacrificed 30 days after implantation; all had stable hemodynamics and minimal hemolysis, as indicated by low plasma free hemoglobin (2.5 ± 3.1 mg/dL). Mean 30-day pump flow was 1.8 ± 0.1 L/min at a pump speed of 12 200 ± 400 rpm. Neither activated clotting time nor activated partial thromboplastin time followed the changes in heparin dose. At necropsy, depositions were observed at the front (n = 1) and rear rotor axial positioning stops (n = 4); improved polishing techniques on the stationary stop surfaces and the addition of a hard-carbon, thin-film coating on the rotating stop of the pumps used for the last two experiments addressed the deposition seen earlier. In conclusion, the PediPump showed excellent hydraulic performance and minimal hemolysis during support for up to 30 days. Depositions observed at the axial positioning stops in earlier experiments were addressed by design and material refinements. We continue to focus on developing effective anticoagulation management in the lamb model as well as on further evaluating and demonstrating pump biocompatibility.

[Surgical therapy for coronary artery stenosis with coronary artery aneurysm in the left main trunk due to Kawasaki disease; report of a case].

A 56-year-old woman was admitted for ST depression in V4 to V6 in electrocardiogram. Coronary angiography showed a coronary artery aneurysm with severe calcification on the bifurcation of the left main trunk and 99% stenosis in the left anterior descending artery. She did not have a history of Kawasaki disease in her childhood. She did not have any risk factors for ischemic heart disease, either. These findings suggested that the coronary artery lesions were related to Kawasaki disease. Percutaneous coronary intervention was impossible due to the location of the aneurysm which was on the bifurcation of the left main trunk. Single vessel coronary artery bypass grafting was performed for the stenosis in the left anterior descending artery. After the surgery, she was put on warfarin for the prevention of thrombus formation in the aneurysm. We report a rare case of coronary artery aneurysm due to Kawasaki disease.

Thoracic endovascular aortic repair of an ascending aortic pseudoaneurysm.

A 74-year-old man with a history of two thoracic aortic repairs, including a modified Bentall procedure using a mechanical valve and total arch replacement, was referred to our hospital with the development of hoarseness. Computed tomography revealed an anastomotic pseudoaneurysm between the prosthetic grafts in the ascending aorta. Two aortic cuffs for abdominal aorta were deployed through the left axillary artery using a transcatheter aortic valve replacement guidewire placed at the supra-aortic mechanical valve during ventricular rapid pacing and were successfully covered with an inlet to the pseudoaneurysm on postoperative computed tomography. The postoperative course was favorable.

Novel technique in frozen elephant trunk positioning method using the ostium of the coronary artery on transesophageal echocardiography as an index.

The frozen elephant trunk (FET) technique is useful in the single-stage treatment of aortic arch aneurysms. Since there is no established implantation method for evaluating the distal end of the FET during surgery, we propose the FET positioning method using the ostium of the coronary artery on transesophageal echocardiography (TEE) as an index. We performed 11 total arch replacement operations using an FET for aortic arch aneurysm. The planned position of the FET was determined by computed tomography (CT), and the distance to the ostium of the coronary artery was measured. Intraoperatively, using TEE as a guide, the FET was implanted using our method. Postoperative CT was evaluated the distance from the planned FET position, and the average and median difference was only 0.96 cm and 0.6 cm, respectively. TEE-guided FET deployment using the coronary artery ostium as an index is a simple and reproducible technique.

Novel implantable device to detect cardiac allograft rejection.

BACKGROUND: Allograft rejection remains the nemesis of solid organ transplantation. Soul Mate is a novel implantable wireless data transmission system that analyzes 9 intramyocardial electrogram parameters recorded from 4 or 6 configurations of 2 or 3 epicardial leads to detect allograft rejection. This study determined the ability of the Soul Mate to detect early rejection of transplanted hearts. METHODS AND RESULTS: Five dogs underwent heterotopic cervical heart transplantation and simultaneous implantation of the Soul Mate's Cardiac Rejection Monitoring Device. Dogs were initially immunosuppressed, but subsequent drug discontinuation allowed allograft rejection to appear. Allograft biopsies were performed at regular intervals to determine rejection grade, which was compared to a calculated rejection score determined as percent change from baseline of values for each intramyocardial electrogram. There was significant correlation between the biopsy results and the evolution of 5 parameters. The strongest correlation (r=0.939; P<0.001) was obtained using the "general median" parameter from 4 configurations, assessed 1 day before the biopsy, with a sensitivity of 85.7% and a specificity of 100% compared to the myocardial biopsy results. CONCLUSIONS: The Soul Mate allograft rejection monitoring system accurately detected transplanted heart rejection in a canine model noninvasively with continuous sampling. This proof-of-concept study suggests that the Soul Mate could be used to more intensely and more frequently monitor cardiac allografts for rejection.

In vivo evaluation of zirconia ceramic in the DexAide right ventricular assist device journal bearing.

Zirconia is a ceramic with material properties ideal for journal bearing applications. The purpose of this study was to evaluate the use of zirconium oxide (zirconia) as a blood journal bearing material in the DexAide right ventricular assist device. Zirconia ceramic was used instead of titanium to manufacture the DexAide stator housing without changing the stator geometry or the remaining pump hardware components. Pump hydraulic performance, journal bearing reliability, biocompatibility, and motor efficiency data of the zirconia stator were evaluated in six chronic bovine experiments for 14-91 days and compared with data from chronic experiments using the titanium stator. Pump performance data including average in vivo pump flows and speeds using a zirconia stator showed no statistically significant difference to the average values for 16 prior titanium stator in vivo studies, with the exception of a 19% reduction in power consumption. Indices of hemolysis were comparable for both stator types. Results of coagulation assays and platelet aggregation tests for the zirconia stator implants showed no device-induced increase in platelet activation. Postexplant evaluation of the zirconia journal bearing surfaces showed no biologic deposition in any of the implants. In conclusion, zirconia ceramic can be used as a hemocompatible material to improve motor efficiency while maintaining hydraulic performance in a blood journal bearing application.

In vivo biocompatibility evaluation of a new resilient, hard-carbon, thin-film coating for ventricular assist devices.

The purpose of this study was to evaluate in vivo the biocompatibility of BioMedFlex (BMF), a new resilient, hard-carbon, thin-film coating, as a blood journal bearing material in Cleveland Heart's (Charlotte, NC, USA) continuous-flow right and left ventricular assist devices (RVADs and LVADs). BMF was applied to RVAD rotating assemblies or both rotating and stator assemblies in three chronic bovine studies. In one case, an LVAD with a BMF-coated stator was also implanted. Cases 1 and 3 were electively terminated at 18 and 29 days, respectively, with average measured pump flows of 4.9 L/min (RVAD) in Case 1 and 5.7 L/min (RVAD) plus 5.7 L/min (LVAD) in Case 3. Case 2 was terminated prematurely after 9 days because of sepsis. The sepsis, combined with running the pump at minimum speed (2000 rpm), presented a worst-case biocompatibility challenge. Postexplant evaluation of the blood-contacting journal bearing surfaces showed no biologic deposition in any of the four pumps. Thrombus inside the RVAD inlet cannula in Case 3 is believed to be the origin of a nonadherent thrombus wrapped around one of the primary impeller blades. In conclusion, we demonstrated that BMF coatings can provide good biocompatibility in the journal bearing for ventricular assist devices.

Mitral annular remodeling to treat functional mitral regurgitation: a pilot acute study in a canine model.

BACKGROUND: The aim of this study was to evaluate the feasibility and efficacy of the injection of a nonabsorbable substance into the base of the left ventricle (LV) to treat functional mitral regurgitation (MR). METHODS: Tyramine-based hyaluronan hydrogel was injected into the base of the LV of the beating heart in a canine model of rapid ventricular pacing-induced functional MR (n = 4). The severity of MR was evaluated by epicardial echocardiography before and after hydrogel injection. RESULTS: The injection improved MR grade from 3.4 +/- 0.8 to 1.3 +/- 0.5 (P = .006) without inducing hemodynamic instability or any evidence of myocardial ischemia. We noted significant decreases in the septal-lateral dimension at the mitral annulus (3.4 +/- 0.4 cm to 2.9 +/- 0.3 cm; P = .039) and MR volume (20.6 +/- 7.3 mm3 to 5.2 +/- 2.2 mm3; P = .044). CONCLUSIONS: A novel treatment consisting of hydrogel injection into the base of the LV between the 2 papillary muscles was found to be feasible and effective for reducing functional MR in a canine model.

The PediPump: a versatile, implantable pediatric ventricular assist device--update IV.

Cleveland Clinic's PediPump (Cleveland, OH, USA) is a ventricular assist device designed for the support of pediatric patients. The PediPump is a mixed-flow ventricular assist device with a magnetically suspended impeller measuring 10.5 mm in diameter by 64.5 mm in length. Progress and achievements for the PediPump program are considered according to the development project's three primary objectives: Basic engineering: along with size reductions, substantial design improvements have been incorporated in each design iteration including the motor, magnetic bearings, axial touch points, and heat transfer path; Anatomic modeling and device fitting studies: Techniques based on computed tomography and magnetic resonance imaging have been developed to create three-dimensional anatomic-modeling and device-fitting tools to facilitate device implantation and to assist in preoperative planning. For in vivo testing, to date, six acute (6-h duration) and nine chronic (30-day target duration) implantations have been performed in sheep; the implantation of the PediPump appears to be relatively easy with excellent hemodynamic performance and minimal hemolysis during support. Cleveland Clinic's PediPump program supported by the National Heart, Lung and Blood Institute's Pediatric Circulatory Support Program has led to the development of a pediatric ventricular assist device that has satisfactory performance in preclinical evaluation and appears to be ready to support a program of clinical testing.

Acute Swine Model for Assessing Biocompatibility of Biomedical Interface Materials.

We established an acute animal model for early, straightforward, and reproducible assessment of a biocompatible material interface. Bilateral femoral artery-to-vein shunts were created in 12 pigs: two tubes per shunt, the left two coated and the right two uncoated. We evaluated two groups: uncontrolled flow (UF; shunt flow unregulated) and controlled flow (CF; shunt flow ∼50 mL/min). For each case on each side, two shunts were evaluated: one for 1 h and the other for 3 h. Arterial blood gas and complete blood count were recorded at baseline, 1, and 3 h. Mean shunt flows were 532 ± 88 mL/min UF and 52 ± 8 mL/min CF. Differences in flow were much smaller in CF (0.5 mL/min; 1% of mean flow) than UF (24.8 mL/min; 5% of mean flow). In UF, significant changes occurred: in pH, from start of shunting through 1 h; in pO2 and pCO2, from start through 3 h. This swine model using bilateral femoral shunts with controlled blood flow provides a reliable, reproducible, easily implemented method by which to evaluate biocompatibility of device coatings at an early stage of investigation.

Aortic dissection late after aortic valve replacement.

We experienced 3 cases of an aortic dissection occurring late after an aortic valve replacement, and successfully treated by an aortic root replacement. An aortic dissection involving the ascending aorta can develop late after an aortic valve replacement, and such an occurrence is associated with a high mortality and morbidity. The development of effective surgical strategies at the initial aortic valve surgery, strict control of blood pressure after aortic valve replacement, serial evaluations of aortic size, and the prophylactic replacement of the ascending aorta for patients with aortic dilatation after aortic valve replacement, all play clinically important roles in preventing an aortic dissection after aortic valve replacement. When an aortic dissection occurs in patients with a previous aortic valve replacement, an aortic root replacement should be performed in order to avoid leaving the fragile diseased aortic wall including the sinus of Valsalva.

Surgical revascularization for acute coronary syndrome: comparative surgical and long-term results.

OBJECTIVE: The purpose of this study was to evaluate the adequate timing of coronary artery bypass grafting (CABG) for acute coronary syndrome (ACS). METHODS: In our institution, emergency CABG has been avoided when possible for ACS patients favoring stabilization with medical therapies, including intra-aortic balloon pumping or percutaneous coronary intervention. After thorough preoperative examinations, an urgent CABG is performed. A total of 67 patients with ACS underwent CABG, comprised of 33 patients receiving an emergency CABG (emergent group: E-G) and 34 patients receiving an urgent CABG (urgent group: U-G). The early and long-term results were evaluated retrospectively. RESULTS: Preoperatively, the incidences of acute myocardial infarction and cardiogenic shock were significantly higher in E-G. No significant differences were found in the intraoperative factors except for the number of distal anastomoses (2.5 in E-G vs. 3.1 in U-G, p=0.01). The hospital mortality was 9.1% in E-G, and 2.9% in U-G, with no significant difference between the groups. Moreover, no patient in U-G necessitated emergency CABG while waiting for surgery. The patency rate of the grafts was 100% in E-G, and 96.2% in U-G. The 5-year survival rate excluding in-hospital death was 80.3% in E-G, and 78% in U-G (p>0.05). The 5-year cardiac event-free rate was 80.3% in E-G, and 80.9% in U-G (p>0.05). CONCLUSION: An emergency CABG can be reserved for ACS patients when symptoms and hemodynamic state are stabilized with medical therapies. Improvements in long-term results can be expected after high quality and complete surgical revascularization.

Ascending aortic replacement for acute type A aortic dissection in octogenarians.

OBJECTIVE: The management of acute type A aortic dissection in elderly patients is controversial. This study aimed to investigate the validity of ascending aortic replacement for acute type A aortic dissection in octogenarians compared with younger patients. METHODS: Twenty-five octogenarians, among 117 consecutive patients with acute type A aortic dissection between January 2000 and October 2013 who underwent emergency surgery, were reviewed retrospectively. The median age was 84 years (80-91 years). The patients were six men and 19 women. All 25 patients underwent ascending aortic replacement under deep hypothermic circulatory arrest. In the same period, 55 patients younger than 80 years with acute type A aortic dissection had ascending aortic replacement performed. Clinical data were prospectively entered into our institutional database. Late follow-up was 6.8 ± 2.8 years and was 100% complete. RESULTS: The 30-day mortality rate was 8% (2/25 patients), which was similar to that in patients younger than 80 years (5%). There were no reoperations in octogenarians and five reoperations in younger patients in the follow-up period. Survival at 1 and 5 years was 80.0 and 59.7% in octogenarians and 90.6 and 81.9% in younger patients, respectively (P = 0.036). CONCLUSION: Ascending aortic replacement for octogenarians with acute type A aortic dissection was successfully performed, resulting in satisfactory early and midterm survival. Aggressive surgical treatment is mandatory for improving the outcome in octogenarians with acute type A aortic dissection.

Impact of transapical aortic cannulation for acute type A aortic dissection.

OBJECTIVE: Early and mid-term result of transapical aortic (TAA) cannulation technique was evaluated compared with femoral artery (FA) cannulation in Acute Type A Aortic Dissection(AAAD). METHODS: From January 2000 to October 2013, 80 consecutive patients with AAAD were underwent the ascending aortic replacement at Nagasaki Kouseikai Hospital. These patients were divided into two groups according to the cannulation site, FA cannulation (n = 34) and TAA cannulation (n = 46). Early and mid-term outcomes were compared between two groups. RESULT: Preoperative patient characteristics were almost comparable between groups. The time from skin incision to starting cardiopulmonary bypass (CPB) was significantly shorter in the TAA group (45 ± 16 vs 23 ± 5.1 min; P <0.001). There were no significant differences in post-operative cerebral infarction in two groups (17% versus 11%; P = NS). The operative mortality rate was 8.8% in FA group and 4.3% in TAA group (P = NS). During follow up (mean, 6.8 years), survival at 3 years and 5 years was 77.4% and 71.9% in TAA group and 76.3% and 73.8% in FA group, respectively. CONCLUSION: The postoperative morbidity and mortality between the two groups were almost the same. TAA cannulation for acute Type A aortic dissection is faster, easy and safe with acceptable early and mid-term outcome.

Left ventricular myxoma originating from the papillary muscle.

A rare case of left ventricular myxoma presenting embolization into the brachial artery is reported. The sessile tumor originated from the posteromedial papillary muscle and involved the chorda supporting the posterior mitral leaflet. Complete excision of the tumor with the posterior head of the posteromedial papillary muscle, with the chorda and with the posterior mitral leaflet necessitated valve replacement. The tumor was well visualized by the superior-septal and transaortic approaches. These enabled exploration of all four cardiac chambers so as not to overlook any multifocal myxoma. The left ventricular myxoma should be completely resected with the surrounding endocardium in order to avoid recurrence of the disease.

Evaluation of coronary artery bypass grafting in acute myocardial infarction.

OBJECTIVES: We evaluated coronary artery bypass grafting (CABG) in acute myocardial infarction (AMI) within 14 days of onset. METHODS: Of 1,450 patients undergoing isolated CABG in the last 12 years we retrospectively analyzed operative risk factors and studied the use of CABG in treating AMI in 66 undergoing surgery during the AMI phase. We divided them into 2 groups: Group D (deceased: n = 8) and Group S (survivors: n = 58). RESULTS: Total operative mortality was 12.1% (8/66). Univariate analysis showed the following preoperative parameters to be significant in Group D: diabetes mellitus, cardiogenic shock, shortness of the interval between AMI onset and surgery, mean peak creatine phosphokinase-MB, AMI of the left main trunk, and failed recanalization of the infarcted artery. Multivariate analysis showed diabetes mellitus, cardiogenic shock, and AMI of the left main trunk as independent risk factors for hospital mortality. Intra-operative parameters between groups showed no statistical difference. Mortality in patients who did not suffer cardiogenic shock was zero. CONCLUSION: Maintenance of hemodynamics in the early phase is vital in treating AMI. The most important element in surgical intervention is revascularization of main branches. We concluded that CABG in AMI involves relatively low risk.

Papillary fibroelastoma of the tricuspid valve.

A 72-year-old male patient was admitted with chest oppression. Echocardiography disclosed a mobile tumor which was located on the atrial side of the tricuspid valve. Neither tricuspid obstruction nor regurgitation was observed. The mobility and the size, 20 mm in diameter, of the tumor indicated the need to perform surgical treatment. Through a right atriotomy, the tumor with multiple papillary fronds was found on the basal zone of the anterior leaflet. A resection of the tumor and tricuspid valvuloplasty with a partial annular reconstruction were performed. A pathological examination confirmed papillary fibroelastoma. He had an uneventful recovery, and postoperative echocardiography detected neither any residual tumor nor tricuspid regurgitation. In conclusion, it is reasonable to state that echocardiography is useful for detecting cardiac tumors, and a surgical resection is indicated for a mobile or large papillary fibroelastoma even when it is located on the right side of the heart.