Extracorporeal Mechanical Circulatory Support Research Articles

The outcomes of a standardized protocol for extracorporeal mechanical circulatory support selection-left ventricular challenge protocol.

There are no criteria for surgical mechanical circulatory system (MCS) selection for acute heart failure. Since 2021, we have utilized cardiopulmonary bypass system to assess patients' heart and lung condition to inform surgical MCS selection. we aimed to retrospectively analyze the outcomes of treatments administered using our protocol. We analyzed the data of 19 patients who underwent surgical MCS implantation. We compared patients' characteristics across the biventricular-assist device (BiVAD), central Y-Y extracorporeal membrane oxygenation (ECMO), central ECMO, and left VAD (LVAD) systems. Patients' diagnoses included fulminant myocarditis (47.4%), dilated cardiomyopathy (21.1%), acute myocardial infarction (15.8%), infarction from aortic dissection (5.3%), doxorubicin-related cardiomyopathy (5.3%), and tachycardia-induced myocarditis (5.3%). Eight patients (42.1%) underwent LVAD implantation, 1 (5.2%) underwent central ECMO, 4 (21.1%) underwent BiVAD implantation, and 6 (31.6%) underwent central Y-Y ECMO. 48h after surgery, both the pulmonary arterial and right atrial pressures were effectively controlled, with median values being 19.0mmHg and 9.0mmHg, respectively. No patients transitioned from LVAD to BiVAD in the delayed period. Cerebrovascular events occurred in 21.1%. Successful weaning was achieved in 11 patients (57.9%), and 5 patients (26.3%) were converted to durable LVAD. Two-year cumulative survival was 84.2%. Our protocol showed good results for device selection in patients with heart failure, and device selection according to this protocol enabled good control of the pulmonary and systemic circulations.

Extracorporeal Mechanical Circulatory Support after Pulmonary Thromboendarterectomy: Experience of One Center.

Pulmonary thromboendarterectomy (PTE) is the treatment for patients with chronic thromboembolic disease. In the immediate postoperative period, some patients may still experience life-threatening complications such as reperfusion lung injury, airway bleeding, and persistent pulmonary hypertension with consequent right ventricular dysfunction. These issues may require support with extracorporeal membrane oxygenation (ECMO) as a bridge to recovery or lung transplantation. This study aims to analyze our series of PTEs that require ECMO. A descriptive and retrospective analysis of all PTE performed at the Favaloro Foundation University Hospital was conducted between March 2013 and December 2023. A total of 42 patients underwent PTE with a median age of 47 years (interquartile range: 26-76). The incidence of patients with ECMO was 26.6%, of which 53.6% were veno-venous (VV) ECMO. Preoperatively, a low cardiac index (CI), high right and left filling pressures, and high total pulmonary vascular resistances (PVRs) were associated with ECMO with a statistically significant relationship. The hospital mortality was 11.9%, and the mortality in the ECMO group was 45.5%, with a statistically significant relationship. Veno-arterial ECMO has a worse prognosis than VV ECMO. Preoperatively, a low CI, high right and left filling pressures, and high total PVRs were associated with ECMO after PTE.

Numerical simulation of the leakage flow of the hydrodynamically levitated centrifugal blood pump for extracorporeal mechanical circulatory support systems.

Extracorporeal centrifugal pumps are widely used in various forms of mechanical circulatory support, including extracorporeal membrane oxygenation and ventricular assist device. A durable centrifugal pump was developed by implementing a new hydrodynamic bearing design that prevents the impeller from touching to the casing wall and provides sufficient washout through the pump to prevent thrombus formation in the pump. The hydrodynamic bearings of the pump are composed of dual annular paths located on both sides of the impeller. Computational fluid dynamics analyses were performed on the flow field inside the pump to estimate the leakage flow through the gap and its impact on the pump efficiency and biocompatibility. The calculations were performed for motor speeds from 3000 to 5000rpm and flow rates from 1.0 to 9.0L/min. The leakage flow increased linearly with increasing pressure head of the pump, and the total leakage flow ranged from 2.0 to 27.3% of the total flow. The average wall shear stresses in the casing bottom ranged from 10.6 to 40.9Pa. The leakage flow of the centrifugal pump with the hydrodynamically levitated impeller had a measurable impact on hydraulic energy losses while enhancing the washout flow to achieve good anti-thrombogenicity.

Scimitar Syndrome Outcomes in Patients with Pulmonary Hypertension: A Single Center Experience

<h3>Purpose</h3> Scimitar syndrome (SS) is a rare congenital heart disease characterized by anomalous pulmonary venous return, with associated right lung hypoplasia. This study aimed to describe the differences in characteristics and outcomes of SS patients with and without pulmonary hypertension (PH). <h3>Methods</h3> This was a retrospective cohort study that included all SS patients followed at a large pediatric institution from October 1989 through August 2021. <h3>Results</h3> A total of 84 patients diagnosed with SS were included (27% with PH). When comparing no-PH with PH patients, PH patients were diagnosed with SS at a younger age (PH: 11 days vs. no-PH: 449 days, p:0.034), frequently symptomatic by the time of diagnosis (PH: 87% vs. no-PH:79%, p:0.538), had often congenital heart disease (PH:87% vs. no-PH: 46%, p: 0.001), history of prematurity (PH: 18% vs. no-PH:11%, p: 0.716), and genetic syndromes (PH:9% vs. no-PH: 3%, p:0.301). Fifty-two percent of the SS PH patients were initiated on PH target therapy (58% phosphodiesterase inhibitors, 8% endothelin receptor antagonists and 33% dual PH target therapy). From the procedural perspective, PH patients underwent more APC occlusion procedures (PH:61% vs. no-PH:41%, p:0.218), had multiple interventional cardiology procedures (PH:83% vs. no-PH:38%, p<0.001) were younger when they underwent their first surgical scimitar vein repair (median age PH:26 months vs. no-PH:84 months, p:0.222), and had a higher incidence of restenosis after interventional cardiac procedures (PH:26% vs. no-PH:8%, 0.040). Only PH patients underwent extracorporeal mechanical circulatory support (9%), and overall had a higher rate of mortality (PH:22% vs. No-PH:5%, p:0.032). <h3>Conclusion</h3> Managing SS patients with PH is an understudied area that requires further data. This study demonstrated that such patients more frequently have a history of congenital heart disease, higher incidence of mortality, and have a greater risk of scimitar vein restenosis compared to non-PH SS patients.

Development of Inspired Therapeutics Pediatric VAD: Benchtop Evaluation of Impeller Performance and Torques for MagLev Motor Design.

Despite the availability of first-generation extracorporeal mechanical circulatory support (MCS) systems that are widely used throughout the world, there is a need for the next generation of smaller, more portable devices (designed without cables and a minimal number of connectors) that can be used in all in-hospital and transport settings to support patients in heart failure. Moreover, a system that can be universally used for all indications for use including cardiopulmonary bypass (CPB), uni- or biventricular support (VAD), extracorporeal membrane oxygenation (ECMO) and respiratory assist that is suitable for use for adult, neonate, and pediatric patients is desirable. Providing a single, well designed, universal technology could reduce the incidence of human errors by limiting the need for training of hospital staff on a single system for a variety of indications throughout the hospital rather than having to train on multiple complex systems. The objective of this manuscript is to describe preliminary research to develop the first prototype pump for use as a ventricular assist device for pediatric patients with the Inspired Universal MCS technology. The Inspired VAD Universal System is an innovative extracorporeal blood pumping system utilizing novel MagLev technology in a single portable integrated motor/controller unit which can power a variety of different disposable pump modules intended for neonate, pediatric, and adult ventricular and respiratory assistance. A prototype of the Inspired Pediatric VAD was constructed to determine the hemodynamic requirements for pediatric applications. The magnitude/range of hydraulic torque of the internal impeller was quantified. The hydrodynamic performance of the prototype pump was benchmarked using a static mock flow loop model containing a heated blood analogue solution to test the pump over a range of rotational speeds (500-6000 RPM), flow rates (0-3.5L/min), and pressures (0 to ~420 mmHg). The device was initially powered by a shaft-driven DC motor in lieu of a full MagLev design, which was also used to calculate the fluid torque acting on the impeller. The pediatric VAD produced flows as high as 4.27L/min against a pressure of 127 mmHg at 6000 RPM and the generated pressure and flow values fell within the desired design specifications. The empirically determined performance and torque values establish the requirements for the magnetically levitated motor design to be used in the Inspired Universal MagLev System. This next step in our research and development is to fabricate a fully integrated and functional magnetically levitated pump, motor and controller system that meets the product requirement specifications and achieves a state of readiness for acute ovine animal studies to verify safety and performance of the system.

Outcome of CentriMag Extracorporeal Mechanical Circulatory Support Use in Critical Cardiogenic Shock (INTERMACS 1) Patients

Outcome of CentriMag Extracorporeal Mechanical Circulatory Support Use in Critical Cardiogenic Shock (INTERMACS 1) Patients

Outcome of CentriMag\u2122 extracorporeal mechanical circulatory support use in critical cardiogenic shock (INTERMACS 1) patients

PurposePrognosis of patients presenting with INTERMACS 1 critical cardiogenic shock is generally poor. The aim of our study was to investigate the results of CentriMag™ extracorporeal short-term mechanical circulatory support as a bridge to decision in patients presenting with critical cardiogenic shock in our unit.MethodsWe retrospectively analysed 63 consecutive patients from January 2005 to June 2017, who were treated with a CentriMag™ device at our institution as a bridge to decision. Patients requiring extracorporeal support for post-cardiotomy shock and for primary graft dysfunction after heart transplantation were excluded.ResultsPatients’ median age was 44 years (IQR 31–52, range 15.4–62.0) and 42 (67%) were male. Primary diagnosis at presentation was ischaemic cardiomyopathy (n = 24; 38.1%), viral myocarditis (n = 19; 30.2%), idiopathic dilated cardiomyopathy (n = 8; 12.7%), and others (n = 12; 19%). The median duration of support was 25 (IQR 9.5–56) days. A total of 7 (11%) patients were supported with peripheral veno-arterial (VA) extra corporeal membrane oxygenation (ECMO), 6 (9%) with central VA ECMO, 8 (13%) with left ventricular assist device (LVAD), 17 (27%) with biventricular assist device (BiVAD), and 25 (40%) with ECMO and then converted to BiVAD. Overall, 22 (34.9%) patients died while on CentriMag™ mechanical circulatory support. Complications included bleeding requiring reoperation/intervention in 24 (38%), renal failure requiring dialysis in 29 (46%), bacterial infections in 23 (37%), fungal infections in 15 (24%), critical limb ischaemia in 6 (10%), and stroke in 8 (13%). The overall survival to successful explant from CentriMag™ was 65.1% (n = 41) and survival to hospital discharge was 58.7% (n = 37). Of these, 10 (16%) had cardiac recovery and were successfully explanted, 20 (32%) were bridged to heart transplantation, 11 (17%) were bridged to long-term left ventricular assist device, 3 (4.7%) were later on transplanted, and 1 (1.6%) recovered to decommissioning. The 1-, 5-, and 10-year survival rates were 55%, 46%, and 23% respectively.ConclusionOur results demonstrate an excellent outcome with the use of the CentriMag™ device in this seriously ill population. Despite requiring multiple procedures, over 58% of patients were discharged from hospital with 5-year survival of 46%.

OC22 ECLS IN PRIMARY REFRACTORY CARDIOGENIC SHOCK: IMPACT OF SHORT-TERM EXTRACORPOREAL MECHANICAL CIRCULATORY SUPPORT ON SURVIVAL

Abstract Background/Aim: Previous studies have demonstrated dubious results of ECMO for the treatment of refractory cardiogenic shock (RCS) after 9 days of support. The use of short-term extracorporeal mechanical circulatory support (ST-MCS) has emerged in the last years. We therefore evaluate the outcome of patients that needed prolonged support and underwent ST-MCS implantation compared to conventional ECMO implantation. Methods: Between January 2009 and October 2017, 183 patients were treated with extracorporeal life support (ECLS) in our centre for primary RCS; we selected the 101 patients that exceed the 9 days of ECLS. 44 cases (44%) were treated exclusively with ECMO implantation (Group 1), while 57 cases (56%) underwent left ventricular or biventricular extracorporeal ST-MCS implantation (Group 2). Among these last patients, in 42 cases the ST-MCS was intended as upgrade of ECMO support. Results: Average duration of the support was 17 ± 9 days in the Group 1 and 13 ± 9 days in the Group 2 (p = 0.08), while mean rates support of the maximal theoretic flow were 62 ± 15% and 79 ± 20% (p &lt; 0.01), respectively. 12 patients of first group and 9 patients of second one died during ECLS support (p = 0.12); 30-days survivals were 61% and 70% (p = 0.24) and rates of hospital discharge were 43% and 61% (p = 0.04), respectively. Kaplan-Meier analysis (Fig.1) demonstrates a better survival in Group 2 rather than in Group 1 (p = 0.04) at median follow-up of 16 ± 24 months. Conclusions: ST-MCS has proved to increase the survival respect single-stage ECMO in patients with primary RCS who need prolonged ECLS and full hemodynamic support.

Approach to pulmonary vascular disease in the ICU.

Pulmonary vascular disease (PVD) complicates the course of many cardiovascular, pulmonary and other systemic diseases in children. The physiological sequelae (pulmonary hypertension and elevated pulmonary vascular resistance) can overwhelm the right ventricle and lead to circulatory collapse. Despite the common end-point, the preceding pathophysiology is complex and variable and requires a tailored approach to diagnosis and management. In this article, we will review the most recent evidence and explore an approach to current controversies in the diagnosis and management of common or challenging patient subgroups. New methods of interpreting data derived from echocardiography and cardiac magnetic resonance imaging may assist in risk stratification and response to therapy. In specific patient subgroups, standard pharmacological therapies to reduce right ventricle afterload may be overutilized, ineffective and in some cases harmful. In the patient failing pharmacological therapy, new and novel techniques are being explored including temporary extracorporeal mechanical circulatory support, pumpless lung assist devices and novel surgical and catheterization procedures. PVD is a diverse entity, and attention to the underlying pathophysiology is essential for appropriate management. Despite significant advances in our understanding, the majority of data comes from small uncontrolled studies and must be interpreted with caution.

Outcome of Centrimag Extracorporeal Mechanical Circulatory Support Use in Critical Cardiogenic Shock (INTERMACS 1) Patients

Overall outcomes of patients presenting with INTERMACS-1 critical cardiogenic shock are generally poor. The aim of our study was to investigate the results of CentriMag extracorporeal short-term mechanical circulatory support as a bridge to decision in patients presenting with critical cardiogenic shock in our unit.

A Novel Surgical Approach to Mechanical Circulatory Support in Univentricular Infants

Historically, the options for mechanical circulatory support in infants, particularly those with single-ventricle physiology, have been limited and outcomes have generally been poor. We report a new approach implemented for long-term support in a series of such patients. This study is a single-center case series of 7 patients with single-ventricle physiology after stage 1 palliation supported with mechanical circulatory support using a novel technique, between May 2014 and September 2015. Our technique included modification and implantation of commercially available pediatric cannulae into the common atrium and the ascending aorta or reconstructed neoaorta and utilization of a centrifugal extracorporeal pump. Median circulatory support duration was 64 days (range, 35 to 99). One adverse neurologic event was observed in 1 patient, and bleeding requiring reoperation in 2 patients. Support to recovery, decision, or heart transplantation was accomplished in all cases. Of all patients, 43% were successfully discharged home. Our experience shows that long-term extracorporeal mechanical circulatory support of patients with underlying single-ventricle physiology after stage 1 palliation is feasible utilizing our technique. This approach overcomes several major challenges encountered in these patients, such as high flow requirement and stability of the cannulae, and allows extubation, rehabilitation, and at times, myocardial recovery.

The Sodium Paradox: Dysnatremia and Mortality in Patients Implanted With Extracorporeal Mechanical Circulatory Support Devices

Dysnatremia, abnormal serum sodium levels, has long been used as a marker for disease progression in heart failure patients. Classically, hyponatremia is associated with increased fluid volume in heart failure and is often a result of neuroendocrine dysfunction and poor cardiac output. Recent studies have noted that dysnatremia and hypernatremia are predictive of worsened outcomes in critical care and renal disease populations. We investigated the relationship between dysnatremia and postoperative outcomes in patients implanted with extracorporeal mechanical circulatory devices. A total of 97 patients who underwent implantation with the CentriMag mechanical circulatory assist system were included in this retrospective study. Patients were divided into 2 groups based on preoperative serum sodium level cutoff of 135 mEq/L. Outcomes and mortality were compared between groups. The mean age for the study population was 56.21 ± 15.13 years, and 57 patients (58.8%) were male. The mean time on CentriMag support was 22.7 days. Patients with serum sodium levels ≤135 mEq/L were noted to have significantly worsened indicators of preoperative cardiac function. However, patients with serum sodium levels >135 mEq/L had significantly shorter postoperative survival ( P = .006). When entered into a multivariate Cox proportional hazards model, sodium was an independent predictor for increased risk of mortality (hazard ratio: 1.224; 95% confidence interval: 1.009-1.485; P = .040). Our results indicate that elevated preoperative sodium in patients undergoing implantation of a temporary mechanical circulatory support system is predictive of worsened postoperative survival.

Development of an Optical Detector of Thrombus Formation on the Pivot Bearing of a Rotary Blood Pump.

Continuous optical monitoring of thrombus formation in extracorporeal mechanical circulatory support (EMCS) devices will contribute to safe, long-term EMCS. A clinically applicable optical detector must be able to distinguish among the optical characteristics of oxygen saturation (SaO2 ), hematocrit (Hct), and thrombus formation. In vitro studies of spectral changes at wavelengths from 400 to 900 nm associated with SaO2 , Hct, and thrombus formed around the top pivot bearing of a Gyro C1E3 pump were conducted. Fresh porcine blood anticoagulated with sodium citrate was circulated in a mock circuit using the pump. The SaO2 , Hct, and anticoagulation activity were altered using an oxygenator, autologous plasma, and calcium chlorite injection, respectively. Light from a xenon lamp was guided by an incident fiber perpendicularly fixed on the top bearing. This light was scattered by blood pooled between the male and female pivots. The detection fiber was perpendicularly fixed against the incident fiber, and the side-scattered light was detected and guided to a spectrophotometer. As a result, light at two different wavelengths, 420 and 810 nm, was identified as suitable for thrombus detection because it was negligibly influenced by SaO2 and was able to detect the optical characteristics of fibrin. The light at these two wavelengths responded more quickly to thrombus formation than the inlet or outlet pressure, and flow rate change. The optical changes showed the changes in Hct around the top pivot bearing, which is caused by the reduction in density of fibrin-trapped red blood cells (RBCs) due to the RBCs being swept away by the surrounding blood flow. The proposed method was also able to detect fibrin production by extracting subtle differences in the optical characteristics between the Hct and thrombus formation.

Repair of anomalous coronary artery from the pulmonary artery: A-signal center 20-year experience

BackgroundAnomalous origin of coronary artery from the pulmonary artery (ACAPA) is a rare congenital coronary malformation with a high mortality whether in infants or adult patients. This study reviews 20years of surgical treatment in a single center and aims to establish the optimal surgical strategies for this rare pathology. Methods and resultsFrom April 1994 to March 2015, 96 consecutive patients aged from 3months to 60years underwent coronary repair surgery. The surgical procedures included ligation (3 cases), ligation along with CABG (6 cases), transpulmonary baffling (Takeuchi Procedure, 14 cases) and directly implantation of the anomalous coronary artery (ACA) into the aorta (73 cases). Postoperative extracorporeal mechanical circulatory support (ECMO) was necessary in 4 cases. Mitral valve repair was performed in 40 patients with moderate or severe mitral regurgitation (MR). Mitral replacement was performed in one patient with severe MR.There were one early and two late deaths. One patient underwent a second operation because Baffle leaks. During mean 10.45±8.96year follow-up (1month–18years), both early and late improvement of left ventricular function was observed in most patients (8 patients lost of follow-up). ConclusionsThe establishment of a two-coronary system is the main goal of surgical therapy today. In different procedures, the direct implantation of the ACA into the ascending aorta is the best method and has good long-term results. ECMO as a bridge to recovery that will play an integral part in moderns' surgical treatment.

Decreased maximum clot firmness in rotational thromboelastometry (ROTEM®) is associated with bleeding during extracorporeal mechanical circulatory support.

We aimed to characterize the coagulation disturbances which may increase the risk of bleeding, thrombosis or death shortly after implantation of an extracorporeal membrane oxygenation (ECMO) or ventricular assist (VAD) device. Antithrombotic treatment was started in 23 VAD and 24 ECMO patients according to the hospital protocol. Additionally, conventional laboratory testing, rotational thromboelastometry (ROTEM®) and platelet function analysis (Multiplate®) were performed at predetermined intervals. Four out of twenty-four (16.7%) of ECMO patients and 6/23 (26.1%) of VAD patients had severe bleeding after the procedure. When all the patients were analyzed together, low maximum clot firmness (MCF) in ExTEM and FibTEM analyses was associated with severe bleeding (p<0.05) and low MCF in FibTEM with 30-day mortality. Low platelet count and hematocrit levels were also associated with severe bleeding. When VAD and ECMO patients were separated into different groups, the association between ROTEM® parameters, bleeding and survival was found only in limited time points. Four patients with VAD had cerebral ischemia indicative of thromboembolism. However, this had no significant correlation with ROTEM® or Multiplate® parameters. Hypocoagulation shown by ROTEM® was associated with bleeding complications in patients with mechanical circulatory support. In contrast, hypercoagulation did not correlate with clinical thrombosis.

(876) - Outcome of CentriMag Extracorporeal Mechanical Circulatory Support Use in Critical Cardiogenic Shock (INTERMACS 1) Patients

Purpose Prognosis of patients presenting with INTERMACS-1 critical cardiogenic shock with multiorgan dysfunction is generally poor. The aim of our study was to investigate the results of CentriMag™ extracorporeal short-term mechanical circulatory support as a bridge to decision in patients presenting with critical cardiogenic shock in our unit. Methods We retrospectively analysed 93 consecutive patients from January 2005 to August 2020, who were treated with a CentriMag™ device at our institution as a bridge to decision. Patients requiring extracorporeal support for post cardiotomy shock and for primary graft dysfunction after heart transplantation were excluded. Results Patients median age was 39.7 years (range 15.4-62.01) and 68 (68.7%) were male. Primary diagnosis at presentation was ischaemic cardiomyopathy (n=32; 34.4%), viral myocarditis (n=28; 30.1%), idiopathic dilated cardiomyopathy (n=15; 16.1%), others (n=18; 19.4%). Median duration of support was 33 (IQR 2 - 124) days. A total of 9 (9.7%) patients were supported with peripheral VA ECMO, 16 (17.2%) with central VA ECMO, 11(11.8%) with LVAD, 36(38.7%) with BiVAD, 21(22.6 %) with ECMO and then converted to BiVAD. Overall 23 (24.7%) patients died while on CentriMag™ mechanical circulatory support. Complications included bleeding requiring reoperation/intervention in 26 (27.9%), renal failure requiring dialysis 44 (47.3%), bacterial infections 33(35.5%), fungal infections in 23(24.7%), critical limb ischaemia 8 (8.6%) and stroke 14(15.1%). The overall survival to successful explant from CentriMag™ was 62.4% (n=58) and survival to hospital discharge was 55.9% (n=52). Of these,16(17.2%) had cardiac recovery and were successfully explanted, 30(32.3%) were bridged to heart transplantation. 11(11.8%) were bridged to long term left ventricular assist device, The 1, 5 and 10 year survival was 58%, 50%, 38% respectively. Conclusion Our results demonstrate an excellent outcome with the use of the CentriMag™ device in this seriously ill population. Despite requiring multiple procedures over 56% of patients were discharged from hospital and 5 year survival of 50%.

Aortic Implantation of Anomalous Origin of the Left Coronary Artery From the Pulmonary Artery: Long-Term Outcomes

Since 1989 all patients with anomalous origin of the left coronary artery from the pulmonary artery at our institution have been treated with aortic implantation. The purpose of this review was to assess the late outcomes of these patients, especially regarding left ventricular (LV) function and mitral valve insufficiency. Between 1989 and 2014, 36 patients had aortic implantation of anomalous origin of the left coronary artery from the pulmonary artery. Mean age at surgery was 2.5 ± 5.1 years (median, 0.5 years). Operative strategy included antegrade cold-blood cardioplegia, main pulmonary artery transection, aortic implantation with a large button of pulmonary artery, pulmonary reconstruction with fresh autologous pericardium, and prolonged postoperative inotropic and ventilator support. Mitral regurgitation and LV dysfunction were graded as 0 to 4 (0 = none, 1 = trivial, 1.5 = trivial-mild, 2 = mild, 2.5 = mild-moderate, 3 = moderate, 3.5 = moderate-severe, and 4 = severe). Mean mitral regurgitation grade preoperatively was 2.95 ± 0.95. Mean LV dysfunction grade was 3.14 ± 1.27. Mean cross-clamp and cardiopulmonary bypass times were 49.1 ± 18 minutes (median, 48.5 minutes) and 147.5 ± 45 minutes (median, 139 minutes), respectively. There was no operative or late mortality. Four patients had delayed sternal closure. Mean duration of ventilator support was 11 ± 6.6 days (median, 9 days). Two patients required 3 and 6 days of postoperative extracorporeal mechanical circulatory support. Mean length of stay was 25 ± 18 days (median, 19 days). No patient has required reoperation for supravalvar pulmonary stenosis, coronary stenosis, or mitral valve repair or replacement. Late echocardiographic follow-up shows a mean mitral regurgitation grade of 1.67 ± 1.05 and a mean LV dysfunction grade of 0.23 ± 0.68. Aortic implantation is our procedure of choice for patients with anomalous origin of the left coronary artery from the pulmonary artery. No patient required mitral valve repair or transplant. There was marked improvement of mitral regurgitation grade, return to essentially normal LV function, and no mortality during a 25-year period.

Delayed sternal closure does not increase late infection risk in patients undergoing left ventricular assist device implantation

Delayed sternal closure (DSC) is employed after conventional cardiac surgery without a significantly increased risk of late mediastinitis or sternal wound infection. There are no data specifically examining its late effects on patients undergoing implantation with a ventricular assist device (VAD). Between October 1996 and October 2010, 364 patients underwent primary VAD implant and DSC was utilized in 184 (51%) patients for coagulopathy (n = 155; 84%), hemodynamic instability (n = 103; 56%), isolated right ventricular dysfunction (n = 15; 8%) or unspecified reasons (n = 17; 9%). Median duration of DSC was 1 day (range 1 to 7 days). Patients with DSC were older (54.5 vs. 50.3 years, p = 0.002), had a higher incidence of previous sternotomy (42% vs. 28%, p = 0.005), pre-operative intra-aortic balloon pump (50% vs. 30%, p < 0.001), pre-operative temporary extracorporeal mechanical circulatory support (23% vs 10%, p < 0.001), lower platelet counts (171,000 vs. 209,000, p < 0.001) and lower hematocrit levels (32% vs. 36%, p < 0.001). Operative (11% vs. 9%, p = 0.65) or late (2 years; 66 ± 7% vs 66 ± 7%, p = 0.720) mortality; composite incidence of mediastinitis, percutaneous drive-line infection, pocket infection and VAD-related endocarditis (15% vs. 16%, p = 0.79); re-exploration for bleeding (18% vs. 18%, p = 0.99); urgent transplantation for infection (4% vs. 3%, p = 0.99); or need for device exchange (9% vs. 10%, p = 0.16) was not increased after DSC when compared with immediate sternal closure. DSC increased ICU stay (10 vs. 5 days, p = 0.001). DSC was performed most commonly for coagulopathy and/or hemodynamic instability, and patients were older with a greater severity of illness as shown by the higher incidence of right-sided circulatory failure and history of prior sternotomy. Although DSC was associated with longer ICU stay, DSC was not associated with a significantly increased risk of death or infection.

G303 血液ポンプシステムを簡易に装着するための脱血管形状に関する検討(GS3-1 流体機械,一般セッション)

G303 血液ポンプシステムを簡易に装着するための脱血管形状に関する検討(GS3-1 流体機械,一般セッション)

Repair of anomalous origin of the left coronary artery from the pulmonary artery in infants and children

Although mortality after direct aortic reimplantation for anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) has significantly decreased, many questions remain unanswered. Between 1986 and June 2010, we operated on 27 consecutive pediatric patients with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). All patients underwent reestablishment of a dual coronary system with direct aortic reimplantation of the left coronary artery into the aorta. Postoperative extracorporeal mechanical circulatory support was necessary in 7 cases. In all 7 patients, hemodynamic stability was achieved after 4 to 10 days of support. Mitral valve repair was performed in 9 patients with severe mitral valve incompetence and resulted in stable mitral valve function during follow-up as long as 19 years. There were no early or late deaths. During follow-up (3 months-17.5 years), both early and late improvement of myocardial function was observed in all patients. Reduced left ventricular regional function late after successful surgical correction of ALCAPA was related to the presence of left ventricular myocardial scar tissue, as detected by magnetic resonance imaging. Despite the absence of early and late mortality, the long-term prognosis for patients after reimplantation of ALCAPA into the aorta is not clear. Scars and perfusion deficits of the left ventricle may not be detected by standard echocardiographic evaluation of global left ventricular function and therefore may be underestimated. We therefore recommend lifelong surveillance of these patients, including magnetic resonance imaging.