Apical Venting Research Articles

Valve-shaped thrombus underneath an aortic bioprosthesis.

We describe massive thrombus formation completely occluding an aortic bioprosthesis in a patient with venoarterial extracorporeal membrane oxygenation and apical venting. The thrombus was surgically removed and the patient recovered with no complications. Timely identification and immediate surgical removal of thrombi may allow patient recovery with no severe complications.

Percutaneous Pulmonary Artery Venting via Jugular Vein While on Peripheral Extracorporeal Life Support.

Peripheral extracorporeal membrane oxygenation (ECMO) setting remains a valid option to treat cardiogenic shock (CS). We investigated a percutaneous approach to unload the left ventricle (LV) while on veno-arterial (v-a) peripheral ECMO support. Between 2017 and 2018, eight patients (three females, mean age: 49.6 years old, and five males, mean age: 58 years old, respectively) suffered refractory CS due to acute myocardial infarction (n = 4), acute myocarditis (n = 2), acute decompensation on chronic heart failure (n = 1), and primary graft failure after heart transplantation (Htx) (n = 1), respectively. After a multidisciplinary CS team discussion, it was decided to proceed with peripheral v-a ECMO placement and percutaneous LV venting via right internal jugular vein access to drain the pulmonary artery (PA), in the hybrid operating room. In a single postcardiotomy case, the PA trunk was vented centrally. Mean ECMO support time was 8.5 days. Seven (87.5%) patients were successfully weaned from ECMO and one (12.5%) successfully bridged to Htx. All patients were successfully discharged after treatment except for a single case who died due to sepsis. In case of not recommended usage of LV apical venting, the adoption of v-a peripheral ECMO support associated with percutaneous PA drainage enables the rapid onset of extracorporeal life support with an effective biventricular unloading.

Abstract 12091: Novel ECMO Cannulation Strategy Expedites Conversion to LVAD

Objectives: Venoarterial (VA) ECMO has emerged as a successful modality for bridging patients with critical cardiogenic shock to durable support. However, LV distention on ECMO impairs RV and lung recovery and can result in the need for a temporary RVAD. Additionally, patients on VA ECMO with organ dysfunction may require ongoing LV assistance for recovery prior to durable LVAD conversion. Placement of a large apical LV vent allows bedside conversion to LVAD and provides time for organ recovery prior to elective durable device implantation. Hypothesis: We hypothesized that LV venting on ECMO accelerates RV recovery, hastening conversion to LVAD. Methods: ECMO cases from January 2012 to April 2014 were reviewed following IRB approval. Sixteen patients met INTERMACS Category 1 criteria who were placed on VA ECMO for cardiogenic or post-cardiotomy shock. Eight patients had LV venting and eight had standard peripheral cannulation. Refractory pulmonary edema, CPR during cannulation, and severe LV distention were indications for LV venting. A 32 French malleable cannula was placed by limited anterolateral thoracotomy into the LV apex. Bedside LVAD conversion was performed by percutaneous decannulation of the venous line and removal of oxygenator from circuit. Results: Conversion to temporary LVAD was successful in all LV vent cases at a mean timepoint of 5.9 (±1.3) days after LV venting compared with 13.5 (±4.9) days in non-vented patients (p = 0.07). RVAD requirement was 25% in non-vented patients and 0% in vented patients. 30-day mortality was 25% for both groups. Conclusions: LV venting as an adjunct to VA ECMO facilitates RV recovery to enable early LVAD conversion at the bedside. It also provides organ recovery time and obviates the need for a temporary RVAD at the time of durable LVAD implantation. In conclusion, the LV apical venting technique allows staged recovery of critically ill patients in biventricular and multiple organ failure with a high survival rate.

Left ventricular apical aneurysm associated with normal coronary arteries following cardiac surgery: Echocardiographic features and differential diagnosis

Left ventricular aneurysms mainly occur in patients with transmural myocardial infarction caused by left anterior descending coronary artery occlusion. Left ventricular apical aneurysm is rarely found in patients with normal coronary arteriograms, and even rarer in these patients following cardiac operations. We analyzed 37 patients with postoperative left ventricular apical aneurysm, including 1 case from our hospital and 36 cases from the literature; 23 cases (62%) had left ventricular apical true aneurysms and 14 cases (38%) had left ventricular apical pseudoaneurysms, all confirmed at surgery and/or angiography. All cases, with the exception of one, had previously undergone cardiac surgery under cardiopulmonary bypass with apical venting. Although left ventriculography is generally regarded as the gold standard for diagnosis of ventricular aneurysm, echocardiography is an accurate and sensitive method in the evaluation of left ventricular apical aneurysm. Differential diagnosis of left ventricular apical aneurysm includes takotsubo cardiomyopathy, post transapical approach for transcatheter aortic valve implantation, and left ventricular diverticulum.

Implant Stability and Histological Evaluation of a Dental Implant Assembly With Tantalum-Based Porous Material: An Experimental Study in Hound Dogs

A porous tantalum material (TM) has an ability to facilitate osseointegration and provide a substrate for cell adhesion that has made it desirable to use in orthopedic surgery1,2. The objective of this study was to compare the implant stability and biological tissue responses of an experimental dental implant assembly with porous TM shell and a tapered self tapping implant with an apical vent (control) placed in the extraction socket (Type 1: immediate placement) of a canine model. A total of 48 implants with 4.1mm diameter and 13mm length (24 each of TM & control) were placed bilaterally in the extraction sockets in premolar and molar regions of the mandibles of six hound dogs (4 implants per side).

Histological Analysis of Soft and Hard Tissues in a Periimplantitis Lesion

Little is known regarding the histologic hard and soft tissue changes that occur in chronic periimplantitis situations in humans. It is critical to gain an understanding of all aspects of periimplantitis to develop appropriate therapeutic approaches. An 83-year-old African American man presented with a fractured implant affected by severe, chronic periimplantitis and surrounded by keratinized gingiva. A trephine biopsy of the implant and surrounding tissues was analyzed histologically. Histological analysis of the periimplantitis specimen revealed significant inflammatory infiltrate consisting predominantly of lymphocytes and plasma cells. In addition, epithelial migration and bone loss to the apical vent were noted. This case report documents a single case of periimplantitis that was left untreated for 7 years. The presence of significant keratinized tissue and a smooth surface implant failed to prevent fibrous encapsulation of the implant.

Spontaneous closure of a left ventricle pseudoaneurysm following apical venting

Cardiac surgery is the second most frequent aetiology of left ventricular pseudoaneurysm (LVP). Left ventricular apical venting is a recognized cause of LVP. Prompt surgical treatment is usually needed since there is a high risk of rupture and spontaneous closure is very rare. We describe a case of spontaneous closure of a left ventricle pseudoaneurysm following apical venting.

Pseudoaneurysm of left ventricular following left ventricular apical venting

Sirs: Left ventricular pseudoaneurysm is a rare complication following transmural myocardial infarction but may also follow chest trauma, inflammatory disease, infective endocarditis, tumors and cardiac surgery [4]. Due to the risk of rupture and death, surgical treatment is recommended when left ventricular pseudoaneurysm is detected [1, 5]. We present a case of pseudoaneurysm of left ventricular following left ventricular apical venting.

Mycotic Left Ventricular False Aneurysm at the Site of an Apical Vent Presenting 24 Years After Aortic Valve Surgery

A 48-year-old man presented with progressive exertional dyspnea, lethargy, and intermittent fever. He had undergone resection of subvalvular aortic stenosis at 12 years of age and subsequent resection of residual subaortic stenosis at 24 years of age when an apical vent had been placed in the left ventricle (LV) and closed with a pledgeted suture. The patient had recovered well after both operations and led an active life. Catheter coronary angiography and ventriculography 4 years before his current presentation showed no significant coronary arterial or LV pathology, except for a pullback gradient of 19 mm HG across the LV outflow tract. Echocardiography subsequently showed progression of mild to moderate subaortic stenosis, mild aortic valve stenosis, and moderate regurgitation. On clinical examination, there was visible pulsation of the left chest and a large pulsatile mass palpable subcostally. The patient was anemic (hemoglobin, 7.5 g/dL). Methicillin-sensitive Staphylococcus aureus was cultured from blood samples, and antibiotics were given accordingly. A chest x-ray showed a large opacity apparently continuous with the apical region of the LV (Figure …

Rate of Paraplegia and Mortality in Elective Descending and Thoracoabdominal Aortic Repair in the Modern Surgical Era

The risk of paraplegia and hospital death is the major concern in the surgical repair of descending and thoracoabdominal aortic pathologies. For specific indications, the evolving technology of endovascular stent grafting is becoming increasingly popular. We reviewed our results for elective surgical repair of various aortic pathologies with respect to this innovative therapeutic background. From July 1993 to April 2006, 56 patients (mean age 55+/-16 years, range 25 to 80 years, 62.5% males) underwent elective surgical repair of the descending (n=37, 66.1%) and thoracoabdominal aorta (n=19, 33.9%), including seven reoperations and five cases of previous endovascular stent grafting. The underlying pathologies were: degenerative aneurysm (n=21), type B aortic dissection (n=24), and Marfan's syndrome with a chronic type B dissection and an increase in the diameter of the descending aorta (n=11), respectively. Most patients were operated using deep hypothermic circulatory arrest. Thirty-day mortality was 5.4 % (n=3). Two patients died of myocardial infarction, one after coronary stent occlusion. Another patient died due to ventricular disruption at the side of the left ventricular apical vent. The rate of paraplegia was 3.6% (n=2) with one case of complete and one of incomplete paraplegia. Survival at five years was 78%. If modern surgical principles are used in elective descending and thoracoabdominal aortic repair, surgery can be performed with a low postoperative risk for hospital death or paraplegia. These results should be taken into account when evaluating alternative therapeutic strategies in patients with similar pathologies.

Bilobar apical pseudoaneurysm after left ventricular venting in a Marfan's patient

A Marfan patient presented with a bilobar apical pseudoaneurysm after repeated surgery. These abnormalities were demonstrated by three-dimensional-echo, Doppler, and CT-reconstruction. The pseudoaneurysm was related to an apical venting procedure. In this case, a conservative approach was chosen, although in general, pseudoaneurysms form an indication for operative correction, because of the risk of rupture and acute tamponade.

Ventricular Fibrosis Suggested by Cardiovascular Magnetic Resonance in Adults With Repaired Tetralogy of Fallot and Its Relationship to Adverse Markers of Clinical Outcome

Late morbidity and mortality remain problematic after repair of tetralogy of Fallot (TOF). We hypothesized that fibrosis detected by late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) would be present in adults with repaired TOF and would be related to adverse markers of outcome. LGE was scored in the right and left ventricles (RV and LV) of 92 adult patients who had undergone TOF repair. RV LGE was seen in all patients at surgical sites located in the outflow tract (99%) or the site of ventricular septal defect patching (98%) and in the inferior RV insertion point (79%) and trabeculated myocardium (24%). LV LGE (53%) was located at the apex consistent with apical vent insertion (49%), in the inferior or lateral wall consistent with infarction (5%), or in other areas (8%). Patients with supramedian RV LGE score were older (38 versus 27 years, P<0.001) and more symptomatic (38% versus 8% in New York Heart Association class II or greater, P=0.001), had increased levels of atrial natriuretic peptide (7.3 versus 4.9 pmol/L, P=0.041), and had a trend to higher brain natriuretic peptide (12.3 versus 7.2 pmol/L, P=0.086), exercise intolerance (maximum VO2 24 versus 28 mL.min(-1).kg(-1), P=0.021), RV dysfunction (RV end-systolic volume 61 versus 55 mL/m2, P=0.018; RV ejection fraction 50% versus 56%, P=0.007), and clinical arrhythmia (26% versus 10%, P=0.039). Non-apical vent LV LGE also correlated with markers of adverse outcome. In a multivariate model, RV LGE remained a predictor of arrhythmia. RV and LV LGE were common after TOF repair and were related to adverse clinical markers, including ventricular dysfunction, exercise intolerance, and neurohormonal activation. Furthermore, RV LGE was significantly associated with clinical arrhythmia.

Repair of ALCAPA in a 4-kg Patient Followed by Successful Weaning and "Off-Pump" Explantation of an Apical Venting Pulsatile LVAD

Even in infants and small children, ventricular assist devices have an emerging role in the treatment of congenital and postcardiotomy heart failure. Extracorporeal pneumatic pulsatile devices are considered the strategy of choice if long-lasting bridge to recovery or transplantation is expected. However, complete explantation of the device may be complicated by hemorrhage and subsequent transfusions due to the establishment of CPB. The present case demonstrates successful weaning and complete removal of an apical venting pulsatile LVAD in a 4-kg infant without the employment of CPB.

Dynamic Assessment of Mitral Valve Repair by Directing Pump Blood into the Left Ventricle

Intraoperative testing has a major role in the evaluation of the results of mitral valve repair. Static evaluations are possible by inspecting the valve. Once the patient is weaned from cardiopulmonary bypass, dynamic assessment can be done by digital palpation through a partially closed left atriotomy or pressure monitoring or by transoesophageal or epicardial echocardiography. Before weaning off cardiopulmonary bypass, dynamic assessment is possible by injection of cold saline or cardioplegic solution into the left ventricle either by a catheter advanced through the aortic valve or through a left ventricular apical vent. Another method is by connecting the apical vent to the arterial line of the cardiopulmonary bypass by short side tubing. Repeated clamping and unclamping of this side tubing and the vent suction tubing will divert the arterial blood into the left ventricle under adequate pressure to test the dynamic function of the valve. This method leads to sudden partial diversion of the pump flow towards the left ventricle and absent vent flow. The perfusion technologist should be aware of this method and make appropriate adjustments in the pumping procedure.

Hemodynamic and Energetic Assessment of Calves Implanted with a Left Ventricular Assist Device (LVAD)

Hemodynamic and ventricular energetic parameters were measured in calves implanted with the air driven Utah Ventricular Assist Device (UVAD). Uptake site was varied to determine the effect of control mode and vacuum augmentation of filing. Uptake was drawn solely from the left atrium or combined with a left ventricular apical vent. LVAD outflow returned to the descending, thoracic aorta. Control modes examined included asynchronous pumping as well as 1:1 and 1:2 synchronous diastolic counterpulsation. The 85cc LVAD, vacuum formed from PELLETHANE, was implanted acutely in four animals and chronically in six (7, 49 and 116 days paracorporeally, 1, 28 and 32 days intrathoracically). Instantaneous blood pressures, intramyocardial pressure, aortic outflow, oxygen consumption, LVAD output and drive parameters were recorded. LVAD output was independent of control mode when the natural heart rate was greater than or equal to 80 beats per minute. Intrathoracically positioned LVADs pumped a mean flow of approximately equal to 5 liters/min without vacuum augmentation of filling. Paracorporeally positioned LVADs pumped approximately equal to 3 liters/min mean flow without vacuum augmentation and up to approximately equal to 6 liters/min with 38 mm Hg of vacuum augmentation of filling. Instantaneous ascending aortic pressure and flow showed distinct beat-to-beat variation depending on LVAD control mode. Lower average ventricular afterload was observed when pumping the LVAD asynchronously or 1:2 synchronously. In one acute preparation, left ventricular myocardial oxygen consumption was reduced from the unassisted average control level by 37% for the asynchronous and 1:1 synchronous control modes with left atrial uptake.(ABSTRACT TRUNCATED AT 250 WORDS)

Ventricular apical vents and postoperative focal contraction abnormalities in patients undergoing coronary artery bypass surgery.

Ventriculograms made 9-15 months after surgery in 48 patients with normal preoperative apical contraction were reviewed to determine the influence of apical venting on apical wall motion in patients undergoing coronary bypass surgery. After interpretation of postoperative apical wall motion, the patients were subdivided into two groups. One group consisted of 34 patients who were vented by inserting a catheter through the apex of the left ventricle and the second group included 14 patients in whom no transventricular vent was made. The two groups were similar clinically and hemodynamically before surgery, and the surgical procedures were similar with the exception of vent site. Following surgery, incidences of graft patency and antegrade flow to the apex were also similar. Nineteen (56%) patients in the apically vented group had apical dyskinesia or akinesia observed on the postoperative ventriculogram while none of the patients who were not apically vented had these findings. None of the patients with apical dyskinesia or akinesia had congestive heart failure following surgery. The postoperative ventriculograms of 12 patients with mitral stenosis who underwent valvulotomy by inserting a Tubbs dilator through the apex were also analyzed. Only one patient (8.5%) had apical dyskinesia or akinesia. Since the patients with mitral stenosis probably did not have significant coronary artery disease, it is possible that the combination of the apical vent and ischemic heart disease was responsible for the focal contraction abnormalities observed.

Technique for correction of mitral insufficiency by leaflet advancement

Summary A technique for reconstructing the mitral valve which is insufficient because of shortness of the leaflet-cord complex has been described. This procedure is not indicated for insufficiency due to primary dilatation of the annulus, or when leaflets are very thick, severely calcified, or cannot be rendered appropriately pliable by debridement. Within the confines of these anatomic restrictions, good results can be obtained. Insufficiency is corrected by adding substance to a leaflet (usually the aortic) in such manner as to advance both the free edge and the commissures. Pericardium has been used as the graft material because it is locally available, autologous, leak-proof, and has excellent conforming properties. The most important technical point in the success of this operation is adequate detachment of the leaflet from the annulus. Usually it is necessary to extend the incision slightly beyond each commissure. This enables the free edge to move down and forward, the intact commissures to turn inward, and the leaflet to engage the opposing leaflet during ventricular systole. A left chest approach has been found preferable for the performance of this procedure. Ventricular fibrillation and an apical ventricular vent are recommended for the avoidance of air embolism. Long-term anticoagulation is recommended if the atrium is very large and/or is fibrillating.