Mechanical Circulatory Assistance Research Articles

Cardiac intensive care unit: where we are in 2023

Cardiac intensive care has been a constantly evolving area of research and innovation since the beginning of the 21st century. The story began in 1961 with Desmond Julian's pioneering creation of a coronary intensive care unit to improve the prognosis of patients with myocardial infarction, considered the major cause of death in the world. These units have continued to progress over time, with the introduction of new therapeutic means such as fibrinolysis, invasive hemodynamic monitoring using the Swan-Ganz catheter, and mechanical circulatory assistance, with significant advances in percutaneous interventional coronary and structural procedures. Since acute cardiovascular disease is not limited to the management of acute coronary syndromes and includes other emergencies such as severe arrhythmias, acute heart failure, cardiogenic shock, high-risk pulmonary embolism, severe conduction disorders, and post-implantation monitoring of percutaneous valves, as well as other non-cardiac emergencies, such as septic shock, severe respiratory failure, severe renal failure and the management of cardiac arrest after resuscitation, the conversion of coronary intensive care units into cardiac intensive care units represented an important priority. Today, the cardiac intensive care units (CICU) concept is widely adopted by most healthcare systems, whatever the country's level of development. The main aim of these units remains to improve the overall morbidity and mortality of acute cardiovascular diseases, but also to manage other non-cardiac disorders, such as sepsis and respiratory failure. This diversity of tasks and responsibilities has enabled us to classify these CICUs according to several levels, depending on a variety of parameters, principally the level of care delivered, the staff assigned, the equipment and technologies available, the type of research projects carried out, and the type of connections and networking developed. The European Society of Cardiology (ESC) and the American College of Cardiology (ACC) have detailed this organization in guidelines published initially in 2005 and updated in 2018, with the aim of harmonizing the structure, organization, and care offered by the various CICUs. In this state-of-the-art report, we review the history of the CICUs from the creation of the very first unit in 1968 to the discussion of their current perspectives, with the main objective of knowing what the CICUs will have become by 2023.

Anatomical Correction of Transposition of the Great Arteries at the Arterial Level with Dacron Patch Closure of Multiple Ventricular Septal Defects under Integrated Extracorporeal Membrane Oxygenation: A Video Presentation

A 5-week-old male child, weighing 4 kg diagnosed with d-transposition of the great arteries with multiple muscular ventricular septal defects, Yacoub’s type-A coronary arterial pattern, successfully underwent arterial switch operation with Dacron patch closure of ventricular septal defects under moderately hypothermic cardiopulmonary bypass and St. Thomas based cold blood cardioplegia under integrated extracorporeal membrane oxygenation. Postoperatively, he required mechanical circulatory assistance for 72 h. At 12 months of follow-up, there was no mitral or tricuspid regurgitation, no neoaortic valve insufficiency with good biventricular function in Ross clinical score of 2.

P52: ECMO Circuit Exchange on a Single Pump Console: Maximizing Mechanical Circulatory Support Resources in the High Census Pediatric Environment

Background: Pediatric hospitals have faced an unprecedented period of high census due to a confluence of respiratory illnesses, resulting in increased use of ECMO for rescue and long-term therapy. Combined with equipment demands imposed by a cardiac surgical program, ECMO disposables and pump console inventories have been stretched to their limits in many centers. Circuit exchanges place additional burden on device numbers, as two pump consoles are typically used for the changeout procedure. We report the case of an infant cardiac surgical patient requiring ECMO circuit exchange while the remainder of appropriately sized systems were in use on other patients in the hospital. Methods: A 3kg infant with complex congenital heart disease on VA ECMO post repair required circuit exchange due to consumptive coagulopathy and significantly increased trans-oxygenator gradient after multiple weeks of support. Due to a concurrent period of high ECMO utilization, a size appropriate replacement system was unavailable. In our institution, cardiac patients under 20kg requiring mechanical circulatory assistance are supported on a roller system with multiple pump heads, allowing conversion from ECMO to cardiopulmonary bypass without exposing the patient to an additional circuit and associated sequalae. After careful planning, the decision was made to build and prime a replacement circuit on the currently used pump base, using one of the accessory roller heads to de-air and recirculate the system. The pump-mounted oxygen tank was used to oxygenate the blood-primed circuit, and an extra heater was used to bring the perfusate up patient temperature. Three-way stopcocks placed on the venous, pre-, and post-oxygenator transducers allowed simultaneous pressure monitoring of both circuits. After a period of recirculation, the new infusion and return lines were handed up to the field and marked with white tape to denote new versus old tubing. A brief period off support was well tolerated as the circuits were changed out at the arterial and venous cannula connections, and subsequently the old circuit was removed from the pump base and discarded. Sweep control was re-established by the on-board mixer and flow meters, and water lines were reconnected to the on-board heater.

“Double Myocardial Infarct Syndrome” resulting from Simultaneous Occlusion of Dual Coronary Arteries: A Double Jeopardy

Angiographic evidence of thrombosis in more than one coronary artery at the same time is uncommon in patients with acute myocardial infarction, and this is hard to identify with routine electrocardiography. Patients may manifest with high-degree atrioventricular block, cardiogenic shock, or sudden cardiac arrest, all of which are potentially fatal outcomes. This case study focuses on a patient who experienced cardiogenic shock, high-degree atrioventricular block secondary to acute anterior-inferior ST-segment elevation myocardial infarction. During the coronary angiogram, thrombotic occlusions of the left anterior descending and right coronary arteries were observed. A patient was salvaged by the use of mechanical circulatory assistance in conjunction with prompt percutaneous coronary intervention of both the culprit arteries. Our case report emphasizes the importance of completing revascularization as soon as possible by opening the culprit arteries and ensuring appropriate mechanical circulatory support to the patient.

Mechanical Circulatory Assistance in Children: Clinical Outcome

In countries where organ donation is scarce, mortality in the pediatric heart transplant waiting list is high, and ventricular assist devices (VADs) are therapeutic alternatives in these situations. Berlin Heart EXCOR is currently 1 of the few VADs specific for children. This retrospective study includes pediatric patients who underwent Berlin Heart EXCOR placement in a Brazilian hospital between 2012 and 2021. Clinical and laboratory data at the time of VAD implantation and the occurrence of complications and outcomes (success as a bridge to transplant or death) were analyzed. Eight patients, from 8 months to 15 years, were included: 6 with cardiomyopathy and 2 with congenital heart disease. Six were on Intermacs 1 and 2 on Intermacs 2. The most common complications observed were stroke and right ventricular dysfunction. Six were transplanted, and 2 died. Those submitted to transplant had a higher mean weight than those who died, with no statistically significant difference. The underlying disease had no impact on the outcome. The group undergoing transplant had lower brain natriuretic peptide and lactate values, but no laboratory variable showed a statistically significant difference in the outcome. A VAD is an invasive treatment with potentially serious adverse effects and is still poorly available in Brazil. However, as a bridge to transplant, it is a useful treatment for children in progressive clinical decline. In this study, we did not observe any clinical or laboratory factor at the time of VAD implantation that implied better outcomes.

The Challenges of Diagnosis and Treatment of Arrhythmogenic Cardiomyopathy: Are We there yet?

Background: we sought to review the evolution in the diagnosis and treatment of Arrhythmogenic Cardiomyopathy (ACM), a clinically multifaceted entity beyond the observation of ventricular arrhythmias, and the outcome of therapies aiming at sudden death prevention in a single center experience. Methods: retrospective analysis of the data of consecutive patients with an implanted cardioverter-defibrillator (ICD) and a confirmed diagnosis of ACM according to the proposed Padua Criteria, who were referred to our center from January 1992 to October 2021. Results: we enrolled 72 patients (66% males, mean age at implant 46 ± 16 years), 63.9% implanted for primary prevention. At the time of ICD implant, 29 (40.3%) patients had a right ventricular involvement, 24 (33.3%) had a dominant LV involvement and 19 (26.4%) had a biventricular involvement. After a median follow-up of 6,1 years [IQR: 2.5–9.9], 34 patients (47.2%) had 919 sustained episodes of ventricular arrhythmias (VA). 27 patients (37.5%) had 314 episodes of life-threatening arrhythmias (LT-VA), defined as sustained ventricular tachycardia ≥200 beats/min. Considering only the patients with an ICD capable of delivering ATP, 80.4% of VA and 65% of LT-VA were successfully terminated with ATP. 16 (22.2%) patients had an inappropriate ICD activation, mostly caused by atrial fibrillation, while in 9 patients (12.5%) there was a complication needing reintervention (in 3 cases there was a loss of ventricular sensing dictating lead revision). During the follow-up 11 (15.3%) patients died, most of them due to heart failure, and 8 (11.1%) underwent heart transplantation. Conclusions: ACM is increasingly diagnosed owing to heightened suspicion at ECG examination and to improved imaging technology and availability, though the diagnostic workflow is particularly challenging in the earliest disease stages. ICD therapy is the cornerstone of sudden death prevention, albeit its efficacy is not based on controlled studies, and VT ablation/medical therapy are complementary to this strategy. The high burden of ATP-terminated VA makes shock-only devices debatable. The progressive nature of ACM leads to severe biventricular enlargement and refractory heart failure, which pose significant treatment issues when a predominant RV dysfunction occurs owing to the reduced possibility for mechanical circulatory assistance.

Fontan failure: phenotypes, evaluation, management, and future directions.

Management of "failing" and "failed" Fontan circulation, particularly the indications, timing, and type of re-intervention, currently remains nebulous. Factors contributing to pathogenesis and mortality following Fontan procedure differ between children and adults. Since organ systems in individual patients are affected differently, we searched the extant literature for a "failing" and "failed" Fontan reviewing the clinical phenotypes, diagnostic modalities, pharmacological, non-pharmacological, and surgical techniques employed, and their outcomes. A total of 410 investigations were synthesised. Although proper candidate selection, thoughtful technical modifications, timely deployment of mechanical support devices, tissue-engineered conduits, and Fontan takedown have decreased the peri-operative mortality from 9 to 15% and 1 to 3% per cent in recent series, pernicious changes in organ function are causing long-term patient attrition. In the setting of a failed Fontan circulation, literature documents three surgical options: Fontan revision, Fontan conversion, or cardiac transplantation. The reported morbidity of 25% and mortality of 8-10% among Fontan conversion continue to improve in select institutions. While operative mortality following cardiac transplantation for Fontan failure is 30% higher than for other CHDs, there is no difference in long-term survival with actuarial 10-year survival of around 54%. Mechanical circulatory assistance, stem cells, and tissue-engineered Fontan conduit for destination therapy or as a bridge to transplantation are in infancy for failing Fontan circulation. An individualised management strategy according to clinical phenotypes may delay the organ damage in patients with a failing Fontan circulation. At present, cardiac transplantation remains the last stage of palliation with gradually improving outcomes.

Laser-Treated Surfaces for VADs: From Inert Titanium to Potential Biofunctional Materials.

Objective. Laser-treated surfaces for ventricular assist devices. Impact Statement. This work has scientific impact since it proposes a biofunctional surface created with laser processing in bioinert titanium. Introduction. Cardiovascular diseases are the world's leading cause of death. An especially debilitating heart disease is congestive heart failure. Among the possible therapies, heart transplantation and mechanical circulatory assistance are the main treatments for its severe form at a more advanced stage. The development of biomaterials for ventricular assist devices is still being carried out. Although polished titanium is currently employed in several devices, its performance could be improved by enhancing the bioactivity of its surface. Methods. Aiming to improve the titanium without using coatings that can be detached, this work presents the formation of laser-induced periodic surface structures with a topology suitable for cell adhesion and neointimal tissue formation. The surface was modified by femtosecond laser ablation and cell adhesion was evaluated in vitro by using fibroblast cells. Results. The results indicate the formation of the desired topology, since the cells showed the appropriate adhesion compared to the control group. Scanning electron microscopy showed several positive characteristics in the cells shape and their surface distribution. The in vitro results obtained with different topologies point that the proposed LIPSS would provide enhanced cell adhesion and proliferation. Conclusion. The laser processes studied can create new interactions in biomaterials already known and improve the performance of biomaterials for use in ventricular assist devices.

A Pediatric Lung Assist System

Respiratory disease remains a pervasive medical condition amongst the pediatric health population. Mechanical ventilation and extracorporeal membrane oxygenation (ECMO) are used to bridge patients to transplant or recovery when conventional therapy fails. Patients undergoing these treatments may be sedated for extended periods of time, resulting in deconditioning of the patient’s musculature. Patients who remain awake on ECMO, however, can participate in physical therapy and combat muscle wasting. Typical ECMO circuits are complex and present a major consumer of hospital resources for these patients undergoing rehabilitation and ambulation. Our research group has pursued the integration of mechanical circulatory and respiratory assistance into a compact platform device, the ModELAS, to address this clinical need. The aim of this review is to summarize published work on the pediatric application of the ModELAS. A breadth of topics will be reviewed, including the design requirements, device evolution, in-vitro results, and in-vivo results of the device.

Invasive hemodynamic monitoring by Swan-Ganz pulmonary artery catheter: concepts and utility

Since its beginnings in the last century, pulmonary artery catheterization (PAC) has evolved into an invasive hemodynamic evaluation technique that can be performed at the patient's bedside through a Swan-Ganz catheter; this procedure has maintained an intermittent course in terms of its use; however, it has currently demonstrated relevance in specific scenarios. The PAC allows access to the central venous circulation, the right heart and the pulmonary artery; it performs the calculation of hemodynamic variables directly or indirectly by means of established formulas and methods. This makes possible to perform an adequate hemodynamic evaluation and classification, perform specific tests (e.g. vasoreactivity test), which help to define the diagnosis, therapeutic , monitor the response to treatment, evaluation prior to advanced therapies (e.g. cardiac transplantation or mechanical circulatory assistance devices), and prognosis in our patients. In this article we discuss the concepts and usefulness of pulmonary artery catheterization.

ELECTIVE MECHANICAL SUB PULMONARY SUPPORT - THE FINAL FRONTIER OF SINGLE VENTRICLE PALLIATION

Sophisticated technology advances are fast taking taking shape to provide long term destination therapy mechanical circulatory assistance. Sai Spandan total articial heart with hybrid BSRM core with dual motor and controls, virtual t technology is one such over the horizon. The promise is of better quality of life and longevity. Transcutaneous charging of fully implantable models would very soon revolutionize cardiac surgical treatment modalities. The nal frontier in a failing Fontan is sub pulmonary mechanical assistance. We take a short look into the issues and possibilities. The research gap exists for the innovator in this eld.

A novel automated simulator of pediatric systemic circulation: Design and applications

The technology of ventricular assist devices has shown unprecedented evolution over the last decade. Despite of it, there is still a great need of developing pediatric specific devices, thus highlighting the demand for flexible simulators, capable of emulating mechanical circulatory assistance in the setting of pediatric heart failure. The aim of this work was to design and build an automated simulator of the pediatric circulation. The simulator comprises a hydraulic circulation mock loop and an electronic system with its computational algorithms and its graphical user interface. The simulator includes left ventricle assist devices capable of generating pulsatile or continuous-flow. To demonstrate the applicability of the automated system developed, normal and heart failure conditions of pediatric patients were simulated and the contribution of left ventricular assist devices in restoring normal hemodynamics were quantified. Restoration of aortic flow was obtained with the use of continuous or pulsatile devices in heart failure simulated conditions. The system is user friendly and intuitive, allowing fast and reproducible adjustments of parameters, such as vascular resistance and compliance, and left ventricle preload, providing environments suitable for in vitro evaluation of pediatric left ventricle assist devices.

Platelet Desialylation Is a Novel Mechanism of Thrombocytopenia during Mechanical Circulatory Assistance

Introduction: Although bleeding associated with thrombocytopenia often complicates mechanical circulatory assistance (MCA), the mechanisms of thrombocytopenia observed in this high shear stress situation remain poorly understood. Recent studies have highlighted that platelet desialylation, a process in which terminal sialic acids are cleaved from glycoconjugates on the platelet surface, leads to accelerate platelet clearance via asialoglycoprotein receptors on hepatocytes and subsequent thrombocytopenia. Moreover, it was demonstrated that platelet receptor GPIba occupancy by plasma protein von Willebrand factor (VWF) under physiological shear stress induces platelet desialylation. As MCA promotes, in the majority of patients, high shear-induced VWF/GPIba interactions, we aimed to investigate whether the thrombocytopenia observed during MCA depends on platelet desialylation.Methods: The effects of MCA on platelet desialylation were assessed i) in vitro using human whole blood or platelets rich plasma (PRP) and an Impella (Abiomed Europe GmbH, Aachen, Germany) circulatory assistance pump providing flow rate of 5 liters by minute and inserted in a loop and ii) in 11 adult patients requiring arteriovenous extracorporeal membrane oxygenation (ECMO) circulatory assistance. Platelet desialylation was measured by flow cytometry using fluorescent lectin, at baseline and after initiation (5, 30, 60, 120 and 180 minutes and 24 hours for patients) of MCA. The blood platelet count and the immature platelet fraction (IPF), a new parameter that reflects the activity of thrombopoiesis, were also determined in patients at baseline and daily after ECMO initiation.Results: In vitro, platelet desialylation levels in whole blood and in PRP increased after 5 minutes of circulatory assistance pump compared to baseline (+216%, p<0.05 and +132%, p<0.05, respectively) and the difference persists over time (at 180 minutes: +244%, p<0.05 in whole blood and +292%, p<0.05 in PRP). In all patients, platelet desialylation levels were higher after 5 minutes of ECMO compared to baseline (+197%, p<0.001) and as in vitro, the difference persist over time (at 180 minutes: +187%, p<0.05 and at 24 hours: +223%, p<0.05). In parallel, a decrease of platelet counts and an increase of IPF were observed in all these patients after 2 days under ECMO with a nadir at 4 days for platelet counts (73 G/L, range: 27-119 G/L) and a zenith at 3 days for IPF (13.75%, range: 5.5-22.0%).Conclusion: The present study is the first to show that MCA increases platelet desialylation within minutes after pump initiation. Thus, thrombocytopenia observed in this context seems dependent on platelet desialylation. Giving these results, further studies evaluating the potential beneficial effects of desialylation inhibitors to prevent or treat MCA associated thrombocytopenia could be valuable. DisclosuresNix:Abiomed: Employment.

Development of the Left Atrial Assist Device for Patients with Heart Failure with Preserved Ejection Fraction: First In Vivo Results

<h3>Purpose</h3> The Left Atrial Assist Device (LAAD) is a novel device in development for mechanical circulatory assistance in patients who have heart failure with preserved ejection fraction (HFpEF). The device is implantable in the mitral position and delivers blood from the left atrium to the left ventricle. We report our results of the first LAAD <i>in vivo</i> implantation to assess the operational performance. <h3>Methods</h3> The LAAD was implanted in calves (<i>n</i>=4; mean weight 78.9 kg) using cardiopulmonary bypass (CPB) support through a left atrial incision. Horizontal mattress sutures were placed circumferentially around the mitral annulus and through the LAAD sewing ring (diameter 29 mm, Fig. 1a). Various pump-operating conditions, including mean pump speeds ranging from 3,600 to 6,000 rpm, were evaluated after the CPB was weaned, and the hemodynamics for each pump setting were recorded. <h3>Results</h3> The LAAD responded to all control inputs and ran as expected during the experiment. The cardiac output and mean aortic pressure increased (from 5.3 to 6.0 L/min, and from 69 to 77 mm Hg, respectively) by increasing the pump speed from 3,600 to 4,400 rpm, while the mean left atrial pressure decreased (from 15.1 to 8.3 mm Hg). These parameters stayed the same at pump speeds of 4,400 to 5,200 rpm. The left ventricular end-diastolic pressure, central venous pressure and heart rate remained stable at speeds ranging from 3,600 to 5,200 rpm. Suction events were occasionally observed at speeds over 4,400 rpm, mainly because of the small size of the left atrium. The epicardial echocardiography showed good positioning of the LAADs, with no evidence of obstruction of the left ventricular outflow tracts (Fig. 1b). <h3>Conclusion</h3> The implantation of the LAADs in calves was successful, and the pump showed intended improvement of the hemodynamics in the normal calf hearts. Additional studies are underway to evaluate the pump performance under diastolic heart failure conditions.

Development of an electrode system for continuous measurement of the volume of an AHV

Mechanical circulatory assistance devices are vital for the patients with end-stage heart failure, who require heart transplantation but are in a waiting list due to the shortage of donor organs. This makes the development of the advanced MCS devices and artificial heart ventricles a crucial task. The systems for the dynamic and adaptive control of circulation parameters are required. AHV liquid volume measurement units must be developed to create such systems. Objective – Determination of the optimal electrode system for the AHV liquid volume measurement unit based on the electrical impedance measurements. The most significant geometrical parameters of the electrode systems for the impedance based AHV liquid volume measurement are determined. The optimal values of the geometrical parameters were found for the system of dynamic AHV liquid volume measurement. Results were confirmed by the numerical and experimental studies. The obtained values of the optimal geometrical parameters of electrode systems will be used in development of biotechnical system of adaptive AHV control.

Neither Preoperative Pulse Pressure nor Systolic Blood Pressure Is Associated With Cardiac Complications After Coronary Artery Bypass Grafting.

Increased pulse pressure has been associated with adverse cardiovascular events, cardiac and all-cause mortality in surgical and nonsurgical patients. Whether increased pulse pressure worsens myocardial injury and dysfunction after cardiac surgery, however, has not been fully characterized. We examined whether cardiac surgical patients with elevated pulse pressure are more susceptible to myocardial injury, dysfunction, cardiac-related complications, and mortality. Secondarily, we examined whether pulse pressure was a stronger predictor of the outcomes than systolic blood pressure. This retrospective observational study included adult cardiac surgical patients having elective isolated on-pump coronary artery bypass grafting (CABG) between 2010 and 2017 at the Cleveland Clinic. The association between elevated pulse pressure and (1) perioperative myocardial injury, measured by postoperative troponin-T concentrations, (2) perioperative myocardial dysfunction, assessed by the requirement for perioperative inotropic support using the modified inotropic score (MIS), and (3) cardiovascular complications assessed by the composite outcome of postoperative mechanical circulatory assistance or in-hospital mortality were assessed using multivariable linear regression models. Secondarily, the association between pulse pressure versus systolic blood pressure and the outcomes were compared. Of 2704 patients who met the inclusion/exclusion criteria, complete data were available for 2003 patients. Increased pulse pressure over 40 mm Hg was associated with elevated postoperative troponin-T level, estimated to be 1.05 (97.5% confidence interval [CI], 1.02-1.09; P < .001) times higher per 10 mm Hg increase in pulse pressure. The association between pulse pressure and myocardial dysfunction and the composite outcome of cardiovascular complications and death were not significant. There was no difference in the association with pulse pressure versus systolic blood pressure and troponin-T concentrations. Elevated preoperative pulse pressure was associated with a modest increase in postoperative troponin-T concentrations, but not postoperative cardiovascular complications or in-hospital mortality in patients having CABG. Pulse pressure was not a better predictor than systolic blood pressure.

Efeitos da supressão da aspiração endotraqueal na incidência de complicações pulmonares no pós operatório de cirurgia cardíaca

INTRODUÇÃO: Aspiração traqueal é utilizada rotineiramente após cirurgia cardíaca para garantir adequada ventilação. OBJETIVO: Verificar se a ausência da aspiração traqueal antes da extubação em pacientes sem sinais de secreção brônquica influencia na incidência de complicações pulmonares, além de repercussões hemodinâmicas e ventilatórias do procedimento e custos. MÉTODOS: Pacientes foram avaliados entre agosto/2012 e julho/2014, divididos igualmente em Grupo ASP (aspiração traqueal prévia à extubação) e NASP (sem aspiração prévia). Foram incluídos indivíduos com: primeira cirurgia cardíaca, idade entre 18 e 75 anos, IMC ? 30 kg/m² e sem doença pulmonar prévia. Foram excluídos indivíduos com tempo de CEC &gt; 120 minutos, necessidade de assistência circulatória mecânica, relação PaO2/FiO2 &lt; 200, SpO2 &lt; 92%, tempo de intubação &gt; 12 horas, PAM &lt; 60 mmHg e sinais de secreção pulmonar. Variáveis hemodinâmicas, ventilatórias, complicações pulmonares e custos hospitalares foram avaliados. RESULTADOS: Foram analisados 228 pacientes (ASP= 114 NASP= 114). FC, PAS, PAD e PAM elevaram-se após aspiração e pós extubação nos grupos, retornando aos valores basais no decorrer do tempo. Não houve diferença estatística na FR e SpO2. Complicações pulmonares representaram 7,8%, sem diferença entre os grupos. CONCLUSÃO: A supressão da aspiração traqueal nos pacientes em pós-operatório imediato de cirurgia cardíaca não influenciou na incidência de complicações pulmonares e evolução clínica pós-operatória. Durante aspiração, houve alterações hemodinâmicas e respiratórias, sem repercussões clínicas, porém estas mesmas alterações ocorreram no grupo NASP após extubação, em menor intensidade. Aspiração endotraqueal sem indicação mostrou-se custosa e com desperdício de tempo dos profissionais.

Mitral Valve Surgery for Papillary Muscle Rupture: Outcomes in 1342 Patients From The Society of Thoracic Surgeons Database

Prior reports of mitral valve surgery (MVS) for ischemic papillary muscle rupture (PMR) have been limited in patient numbers. This study evaluated national outcomes of MVS for PMR using The Society of Thoracic Surgeons (STS) National Database. The study cohort was composed of patients undergoing MVS for ischemic PMR between 2011 and 2018 in the STS registry. Concomitant procedures were included. The primary outcome was operative mortality. Secondary outcomes included STS major morbidities. Multivariable logistic regression was employed for risk adjustment using clinically important variables as well as those predictive in univariate analysis. A total of 1342 patients underwent MVS for PMR during the study period. Most of these were mitral valve replacements (79.8%; n= 1071) and were performed emergently (52.0%; n= 698). Concomitant coronary artery bypass grafting was performed in 59.3% (n= 796). Mechanical circulatory assistance before MVS included intraaortic balloon pump (56.9%; n= 764), Impella pump (4.1%; n= 55), and extracorporeal membrane oxygenation (3.1%; n= 41). The STS predicted risk for mortality was 16.9% ± 15.4%. Operative mortality was 20.0%. Blood products were transfused in 70.7% (n= 949). Major morbidity rates included prolonged ventilation (61.8%; n= 829), acute renal failure (15.4%; n= 206), reoperation (10.2%; n= 137), and stroke (5.2%; n= 70). Multivariable predictors of operative mortality included mitral valve replacement, older age, lower albumin, cardiogenic shock, ejection fraction less than 25%, and emergent salvage status. These data provide a national overview of outcomes after MVS for PMR. Rates of mortality and morbidity are high, but most patients survive operative intervention in this high-risk and otherwise lethal condition.

Aortic thrombosis due to a competitive blood flow with double mechanical circulatory assistance.

Aortic thrombosis due to a competitive blood flow with double mechanical circulatory assistance.

Mechanical Circulatory Support of the Right Ventricle for Adult and Pediatric Patients With Heart Failure.

The clinical implementation of mechanical circulatory assistance for a significantly dysfunctional or failing left ventricle as a bridge-to-transplant or bridge-to-recovery is on the rise. Thousands of patients with left-sided heart failure are readily benefitting from these life-saving technologies, and left ventricular failure often leads to severe right ventricular dysfunction or failure. Right ventricular failure (RVF) has a high rate of mortality caused by the risk of multisystem organ failure and prolonged hospitalization for patients after treatment. The use of a blood pump to support the left ventricle also typically results in an increase in right ventricular preload and may impair right ventricular contractility during left ventricular unloading. Patients with RVF might also suffer from severe pulmonary dysfunction, cardiac defects, congenital heart disease states, or a heterogeneity of cardiophysiologic challenges because of symptomatic congestive heart failure. Thus, the uniqueness and complexity of RVF is emerging as a new domain of significant clinical interest that motivates the development of right ventricular assist devices. In this review, we present the current state-of-the-art for clinically used blood pumps to support adults and pediatric patients with right ventricular dysfunction or failure concomitant with left ventricular failure. New innovative devices specifically for RVF are also highlighted. There continues to be a compelling need for novel treatment options to support patients with significant right heart dysfunction or failure.