Left Ventricular Venting Research Articles

Misplacement of Left Ventricular Vent as a Cause of Cardioplegia Failure During Routine Open-Heart Surgery

We report an unusual cause of failure of successful delivery of antegrade cardioplegia through the aortic root that was caused by the accidental passage of the left ventricular vent catheter across the aortic valve producing acute aortic regurgitation. This problem is best prevented.

Valve-Sparing Aortic Root Replacement and Neochordal Repair of Complex Aortic Leaflet Pathology for Ruptured Sinus of Valsalva Aneurysm Fistulizing to the Right Ventricle

Sinus of Valsalva aneurysms (SVAs) are rare congenital entities arising from eccentric aortic root dilatation that can protrude and rupture into adjacent cardiac chambers. Treatment entails aneurysmal sac excision and aortic defect closure. We present a young patient with a ruptured SVA fistulizing into the right ventricle and acute decompensated heart failure. He also had moderate aortic root enlargement and a dysmorphic aortic valve with 3 highly asymmetrical leaflets. This pathologic condition was successfully repaired with a novel combination of valve-sparing root replacement, aortic valve leaflet neochordal repair, right ventricular reconstruction, and tricuspid valve annuloplasty.

Extracorporeal life support with an integrated left ventricular vent in children with a low cardiac output

The aim of this study was to evaluate our experience in central extracorporeal life support with an integrated left ventricular vent in children with cardiac failure. Eight children acquired extracorporeal life support with a left ventricular vent, either after cardiac surgery (n = 4) or during an acute cardiac illness (n = 4). The ascending aorta and right atrium were cannulated. The left ventricular vent was inserted through the right superior pulmonary vein and connected to the venous line on the extracorporeal life support such that active left heart decompression was achieved. No patient died while on support, seven patients were successfully weaned from it and one patient was transitioned to a biventricular assist device. The median length of support was 6 days (range 5-10 days). One patient died while in the hospital, despite successful weaning from extracorporeal life support. No intra-cardiac thrombus or embolic stroke was observed. No patient developed relevant intracranial bleeding resulting in neurological dysfunction during and after extracorporeal life support. In case of a low cardiac output and an insufficient inter-atrial shunt, additional left ventricular decompression via a vent could help avoid left heart distension and might promote myocardial recovery. In pulmonary dysfunction, separate blood gas analyses from the venous cannula and the left ventricular vent help detect possible coronary hypoxia when the left ventricle begins to recover. We recommend the use of central extracorporeal life support with an integrated left ventricular vent in children with intractable cardiac failure.

Transapical Left Ventricular Vent (TLVV) during veno-arterial ECMO support: a bridge to solution in acute cardiogenic shock

Introduction: One of the main limitations of Veno-Arterial ECMO (VA-ECMO) support is the inappropriate unloading of the Left Ventricule (LV). The increased risk of pulmonary edema and impairs LV function reduces the possibility of a recovery or the feasibility of other definitive treatments such as permanent LVAD implantation or emergency heart transplantation. The solution proposed by our center is the surgical implantation of a transapical LV vent (TLVV) through a minimal invasive approach. TLVV reduces significantly the pulmonary edema and it gave the chance to convert VA- ECMO circuit to a short-term LVAD as a bridge to solution. Methods: From January 2010 to June 2012, 16 consecutive pediatric and adult patients supported by pheripheral AV ECMO for acute profound cardiogenic shock underwent TLVV implantation. Cannulation was done in the ICU through a mini-torachotomy with the seldinger technique using an arterial high-flow multiperforated cannula. TLVV was subsequently connected to the venous inflow line of the AV ECMO. The switch from AV ECMO to short term LVAD has been done in two stages: the weaning from the right circulatory support (intermediate stage: A-A ECMO) and the subsequent weaning from the oxygenator. Results: In-hospital mortality was%. In 12 patients (75,0%) pulmonary function significantly improved after implanting TLVV and the VA ECMO circuit was simplified to a short term LVAD through an intermediate stage of A-A ECMO in order to evaluate the right ventricular and the pulmonary function in two different times. Ten pts were successfully bridged to a definitive treatment: heart transplantation in 3 patients, permanent LVAD implantation in 2 patients and bridge to recovery in 5 patients. In hospital survival in patients arrived to these solutions was 8/10 (80,0%). Conclusions: In our series the double drenaige both of the right and the left side of the heart improved pulmonary function and it gave the possibility to switch from the VA ECMO to a short-term LVAD in the majority of cases. After clinical stabilization of patients it was possible to access to a definitive treatment. We think that in the setting of an VA ECMO, TLVV implantation is useful in order to identify the best candidate for permanent LVAD, heart transplantation or recovery reducing significantly the risk of unsuccess.

Is elimination of cardiotomy suction preferable in aortic valve replacement? Assessment of perioperative coagulation, fibrinolysis and inflammation

Guidelines recommend the avoidance of direct return of pericardial blood based on evidence from coronary surgery. A continuous auto-transfusion system (CATS) can be a good alternative to cardiotomy suction by reinfusing aspirated pericardial blood without the necessity of intermittent collection. To clarify the effects of direct return of pericardial blood in aortic valve replacement (AVR), we compared the effects of cardiotomy suction and an alternative CATS on perioperative coagulofibrinolysis and inflammation systems, and clinical outcomes. In 40 AVR operations between April 2009 and April 2011, the retransfusion method of pericardial blood during cardiopulmonary bypass (CPB) was allocated to the use of cardiotomy suction (non-Cell-Saver group, n = 20) or CATS (Cell-Saver group, n = 20) under identical protocols of anticoagulation and transfusion. The blood from the left ventricular vent was returned to the venous reservoir. We obtained blood samples at nine points up to the morning after surgery. Perioperative values for coagulofibrinolysis markers, such as thrombin-antithrombin III complex, fibrinogen degeneration products, D-dimer and plasmin-α2 plasmin inhibitor complex, were significantly lower in the Cell-Saver group than those in the non-Cell-Saver group from 1 h after the initiation of cardiopulmonary bypass to 3 or 6 h after termination of cardiopulmonary bypass (P < 0.05 for all markers). A fibrinolysis inhibition marker of plasminogen activator inhibitor-1 and the inflammation markers of interleukin-6, 8 and 10 as well as tumour necrosis factor-α were not significantly different. The amount of packed red blood cells required after the termination of CPB was significantly less in the Cell-Saver group compared with that in the non-Cell-Saver group (P = 0.004). There were no significant differences in the other clinical outcomes between the two groups. In AVR, the avoidance of direct return of pericardial blood induced considerable suppressions of coagulofibrinolysis responses. A CATS is a favourable alternative for managing pericardial blood during cardiopulmonary bypass. Our results support the published guidelines and could help to establish ideal strategies for eliminating the use of cardiotomy suction, thus facilitating less-invasive valve surgeries with marked suppression of coagulofibrinolysis responses.

Transapical Left Ventricular Vent (TLVV) during Artero-Venous ECMO Support: A Bridge to Solution in Acute Cardiogenic Shock

Purpose One of the main limitations of artero-venous ECMO (AV-ECMO) support is the inappropriate unloading of the left ventricle (LV). The increased risk of pulmonary edema and impairs LV function reduces the possibility of recovery or the feasibility of a permanent LVAD implantation or heart transplantation. The solution proposed is the surgical implantation of a transapical LV vent (TLVV) through a minimally invasive approach. TLVV reduces significantly the pulmonary edema and it gives the chance to convert AV- ECMO circuit to a short-term LVAD as a bridge to solution. Methods and Materials From January 2010 to June 2012, 16 patients supported by pheripheral AV ECMO for cardiogenic shock underwent TLVV implantation. Cannulation was done through a mini-torachotomy with the seldinger technique using an arterial high-flow cannula. TLVV was connected to the venous inflow line of the AV ECMO. The switch from AV ECMO to short term LVAD has been done in two stages: the weaning from the right circulatory support (intermediate stage: A-A ECMO) and the subsequent weaning from the oxygenator. Results In-hospital mortality was 47,5 %. In 12 patients (75,0%) pulmonary function significantly improved. AV ECMO circuit was simplified to a short term LVAD in 10 patients. Ten pts were bridged to a definitive treatment: heart transplantation in 3 patients, permanent LVAD implantation in 2 patients and bridge to recovery in 5 patients. In hospital survival in patients arrived to these solutions was 8/10 (80,0%). Conclusions TLVV improved pulmonary function and it gave the possibility to switch from the A-V ECMO to a short-term LVAD. After clinical stabilization of patients it was possible to access to a definitive treatment. We think that in the setting of an AV ECMO, TLVV implantation is useful in order to identify the best candidate for permanent LVAD, heart transplantation or recovery reducing significantly the risk of unsuccess.

Central extracorporeal life support with integrated left ventricular vent in children with low cardiac output: Pathophysiologic considerations

Introduction: For children with low cardiac output, extracorporeal life support (ECLS) is the mainstay of mechanical circulatory support. In this study, we reviewed our experience in central ECLS with integrated LV vent in children with intractable cardiac failure.

EComment. The use of mechanical assistance devices in post-infarction ventricular septal defects

We read with great interest the paper by Papalexopoulou et al. regarding the best timing for surgery in patients with post-infarct ventricular septal defects (PVSD) [1]. As outlined by the authors, the patients' haemodynamic status, particularly when the pulmonary-to-systemic (Qp/Qs) shunt ratio is high, dictates the timing of surgery. The majority of patients, up to 89% in the presented series, were operated within the first week from diagnosis. Their mortality was reported to be high, ranging from 31%-75%, as opposed to the more favourable outcome in those operated later (0-18.4 %). It is intuitive that if feasible, reparative surgery should be delayed, while the patient is supported with both drugs and devices. The intra-aortic balloon pump (IABP) is the preferred short-term mechanical circulatory support (MCS), used up to 76% preoperatively in the presented series. In a relatively recent era, the good results of MCS other than IABP as a bridge-to-transplantation support, has led clinicians to extend their use to patients with acute cardiogenic shock related to PVSD. Although promising, the early experience with PVSD patients was not as good as expected. Meyns et al. [2] reported sudden pump failure due to necrotic debris aspiration and impeller clogging in two cases. In another case report, the Heartmate I (Thoratec Corporation, Pleasanton, CA, USA) failed to support the patient due to newly developed PVSD with a sudden increased right-to-left shunt through the pump that eventually led to irreversible hypoxic brain injury [3]. The unsuccessful outcome was related in the first case to the left ventricular venting with high rotational speed of the Hemopump (Medtronic, Inc, Minneapolis, MN, USA), while in the second it could be ascribed to the concomitant surgical closure of the PVSD and pump insertion in a recently infarcted ventricle. Recently, the Impella Recover LP (Abiomed Inc, Danvers, MA, USA) was successfully used as a bridge-to-surgery support in patients with PVSD. Patane et al. reported the successful use of this device in single cases, while the largest published series encompassed 5 patients with posterior PVSD supported for 14.4 ± 6 days until heart transplantation or surgical closure [4]. This device can be implanted percutaneously and can provide a blood flow up to 4 l/min. In this series, the timing of MCS implantation ranged from immediately after the diagnosis of PVSD up to two days of watchful waiting. After support initiation, the Qp/Qs shunt ratio as well as the systolic pulmonary artery pressure and the pulmonary capillary wedge pressure significantly decreased. also an effective increase of the cardiac index (CI) was noted. Mean duration of support was 14.4 days (range 8-23 days) and all patients were successfully bridged to surgery (4 patch closure ± CABG; 1 heart transplantation). There were two early deaths (one due to right ventricular failure and one non-cardiac related) and one late death. Taking these experiences together, even if the use of MCS in acute PVSD management is still limited, the new generation devices and particularly the Impella® system, seem promising for the treatment of these patients. In the ISAR-SHOCK trial [5] the Impella LP 2.5, a percutaneous version of the aforementioned device, was compared to IABP for the treatment of cardiogenic shock. Although the presence of PVSD was an exclusion criterion, as the Impella provided superior haemodynamic support, positive conclusions could be drawn onits efficacy, even in PVSD-related acute cardiogenic shock. Early surgery in these patients bears high perioperative risk, but in some cases cannot be safely delayed. We strongly believe that further research (e.g. prospective randomized trial) is needed to evaluate the best mechanical support and unloading configuration (i.e. left ventricular vs. left atrial venting) for a successful “bridge-to-surgery” in PVSD patients. Conflict of interest: none declared

High Left Ventricular Vent Return After Left and Right Ventricular Assist Device Placement in a Patient With a Mechanical Aortic Valve

High Left Ventricular Vent Return After Left and Right Ventricular Assist Device Placement in a Patient With a Mechanical Aortic Valve

Extra-anatomic Bypass Graft for Recurrent Aortic Arch Obstruction

Extra-anatomic Bypass Graft for Recurrent Aortic Arch Obstruction

Deep hypothermia and aortic regurgitation without left ventricular venting, an animal model

Objective. Omitting ventricular decompression in resternotomy during cardiopulmonary bypass with deep hypothermia and circulatory arrest in patients with aortic regurgitation (AR) has recently been reported. The consequences of the dilated and non-dilated heart in conjunction with rapid and profound cooling were further studied in this randomized animal model. Methods. In five pigs (group A) AR was induced before cooling to 15°C and circulatory arrest of 30 minutes without left ventricular decompression. The animals were rewarmed with a competent valve, and weaning off bypass was attempted. In another five pigs (group B) the protocol was repeated with left ventricular decompression. Hemodynamics and the extent of myocardial infarction were evaluated. Results. During cooling in group A mean arterial and left atrial pressures were equalized and all animals suffered massive pulmonary edema. Only one animal could be weaned off bypass. The remaining four suffered considerable biventricular failure and succumbed when weaned off bypass. The animals in group B were stable throughout the experiment and easily weaned off bypass. Myocardial infarction was significantly more extensive in group A, 22 (6–36)% of left ventricular area, compared to group B; 3 (3–11)%, p = 0.016. Conclusions. In our experimental model aortic regurgitation without left ventricular venting in deep hypothermia and circulatory arrest has damaging effects on the myocardium.

Re-do sternotomy for complex aortic surgery under deep hypothermic circulatory arrest: left ventricular vent - an invaluable adjunct

Re-do sternotomy for complex aortic surgery under deep hypothermic circulatory arrest: left ventricular vent - an invaluable adjunct

Technique for the Repair of Truncus Arteriosus to Maintain Pulmonary Artery Architecture

Technique for the Repair of Truncus Arteriosus to Maintain Pulmonary Artery Architecture

Foreign Material Reaction to BioGlue® as a Possible Cause of Cardiac Tamponade

We describe the case of a 65-year-old female patient who underwent aortic valve reconstruction for aortic valve stenosis. During the operation, repair of a left ventricular laceration produced by a left ventricular vent was necessary. BioGlue® (CryoLife, Atlanta, GA, USA) and pledgeted sutures were used for repair. Pericardial effusion with signs of cardiac tamponade developed five months later. The patient was treated successfully by the removal of all foreign material and part of the BioGlue®. Microbiological findings were sterile. Histology showed a chronic granulomatous inflammatory response suggesting a foreign material reaction to BioGlue® as the cause of the effusion. Though all visible material was removed, the risk of pericardial effusion still persists as part of the BioGlue® remained within the ventricular wall.

Aorta non-clamp technique in case of sclerotic ascending aorta during coronary artery bypass grafting

We read with great interest the manuscript by Antunes MJ in which the author presented an open-anastomosis technique for proximal vein-graft anastomoses in case of sclerotic ascending aorta [1]. We present our comments on the paper from a few technical aspects. A similar technique has already been published by our group in 2006 [2]. We routinely prefer fibrillation without intermittent cross-clamping in the presence of calcification at the ascending aorta. Cardiopulmonary bypass is instituted by cannulation of right atrium and aortic arch, axillary artery, femoral artery or disease-free segment of ascending aorta depending on the extent of the atherosclerotic aortic disease [2]. We always institute a vent to prevent myocardial distension and permit unloading. A left ventricular vent through the right superior pulmonary vein, a pulmonary arterial vent or, sometimes, both may be inserted. A pulmonary arterial vent is safer and does not require special care of the perfusionist against air embolism when compared with a left ventricular vent [3]. We start with the distal anastomoses to the easily accessible coronary arteries as the cooling is started. At 29—30 8C, the heart usually fibrillates spontaneously; however, the patient is cooled down to 28 8C. The mean arterial pressure is kept 65 mm Hg until all the distal anastomoses are completed [2,3]. Additionally, following each distal anastomosis, heart is defibrillated, by which, we believe the conduction tissue replenishes the energy stores. Moreover, this measure is helpful to prevent bundle or branch blocks whichmay occur in the postoperative period [3]. Necessarily, consecutive anastomoses are performed with consequent fibrillation and defibrillation periods [2,3]. Before anastomosing the internal thoracic artery to the left anterior descending artery, we perform the proximal anastomoses. Proximal anastomoses are performed to the clean segments of the ascending aorta [1—3] if available on low flow with mean arterial pressure of 20—25 mm Hg, otherwise to the innominate or the internal thoracic artery [2,3]. We place ice bags around the head of the patient and the table is tilted to place the patient in the Trendelenburg position during low flow. Each proximal anastomosis lasts 3 min and, between each proximal anastomosis, flow is increased to normal. The bypass of the internal thoracic artery to left anterior descending artery is fashioned during re-warming to attenuate the hypothermic period. At the end of the bypass procedure, the heart is defibrillated if necessary [2,3]. Single or multiple clamping of the aorta during conventional cross-clamp cardioplegia and intermittent cross-clamp fibrillation techniques carries high risk of embolisation of the atheromatous material in the presence of a calcified ascending aorta [1—3]. The aorta non-clamp technique is a safer alternative in this particular group of patients. It may be performed on a fibrillating or decompressed beating heart [1]. However, we believe the institution of a vent is important for better myocardial protection.

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.

A Transthoracic, Left Ventricular Vent Facilitates Challenging Sternal Reentry

In this brief report, we describe a technique to facilitate hypothermic arrest before a redo sternotomy that is likely to require extensive dissection. This approach may be well-suited for patients with significant aortic insufficiency, as it allows control of left ventricular distention once hypothermic ventricular fibrillation ensues. The procedure entails inserting a second venous cannula through the left ventricular apex through a 7-cm left mini-thoracotomy. We used the technique successfully in a patient with a ruptured, infected ascending aortic pseudoaneurysm and severe aortic insufficiency who had undergone a previous sternotomy.

Use of the Seldinger Type Movement Over a J-Shaped Stylet for Left Ventricular Vent Insertion

Access through the right superior pulmonary vein is a commonly used route for left ventricular vent insertion. Complex reshaping of the stylet and vent into a certain position or external guidance do not guarantee successful placement. In this article we describe a modified technique where the stylet sets up the position to allow consistent atraumatic advancement of the catheter across the mitral valve.

Acute Valvular Regurgitation

Acute severe valvular regurgitation is a surgical emergency, but accurate and timely diagnosis can be difficult. Although cardiovascular collapse is a common presentation, examination findings to suggest acute regurgitation may be subtle, and the clinical presentation may be nonspecific. Consequently, the presentation of acute valvular regurgitation may be mistaken for other acute conditions, such as sepsis, pneumonia, or nonvalvular heart failure. Although acute regurgitation may affect any valve, acute regurgitation of the left-sided valves is more common and has greater clinical impact than acute regurgitation of right-sided valves. Data to guide appropriate management of patients with acute regurgitation are sparse; there are no randomized trials, and much of the literature describes either small series or the experiences of specific centers. Despite these limitations, the available data are sufficient to allow identification of general principles as well as development of applicable guidelines from both the American College of Cardiology/American Heart Association and European Society of Cardiology. The guidelines recommend valve surgery for symptomatic patients with aortic or mitral regurgitation, including those with acute regurgitation.1–3 The data and guidelines emphasize overarching clinical principles, including the need for a high clinical suspicion of acute regurgitation, timely use of echocardiography, and, in the majority of patients, rapid progression to surgery. Causes of acute regurgitation overlap with causes of chronic regurgitation and vary depending on the valve affected (Table 1). Endocarditis may affect either the aortic or mitral valve, whereas other causes are unique to the specific valve involved. The majority of causes of acute regurgitation present as an acute or subacute event. However, acute regurgitation can occur in patients with chronic regurgitation, when regurgitant severity is exacerbated by factors such as coronary ischemia, chordal rupture, or leaflet perforation from endocarditis. Acute regurgitation of either the aortic or mitral valve may result from procedural …

Valve-Sparing Aortic Root Replacement With the Valsalva Graft

Valve-Sparing Aortic Root Replacement With the Valsalva Graft