Prolonged Mechanical Circulatory Support Research Articles

Clinical characteristics and outcomes of patients requiring prolonged mechanical circulatory support after high-risk percutaneous coronary intervention.

There are limited data on the clinical characteristics and outcomes of patients who require prolonged mechanical circulatory support (MCS) after Impella-supported high-risk percutaneous coronary intervention (HR-PCI). The aim of this study is to describe the contemporary clinical characteristics, outcomes, and predictors associated with prolonged MCS support after assisted HR-PCI. Patients enrolled in the prospective, multicentre, clinical endpoint-adjudicated PROTECT III study who had undergone HR-PCI using Impella were evaluated. Patient and procedural characteristics and outcomes for those who received prolonged MCS beyond the duration of their index procedure were compared to those in whom MCS was successfully weaned and explanted at the conclusion of the index PCI. Among 1,155 patients who underwent HR-PCI with Impella between 2017 and 2020 and had sufficient data to confirm theduration of Impella support, 16.5% received prolonged MCS (mean duration 25.2±31.1 hours compared with 1.8±5.8 hours for those who only received intraprocedural MCS). Patients receiving prolonged support presented with more urgent indications (e.g., acute coronary syndromes [ACS], lower ejection fraction [EF], elevated baseline heart rate and lower systolic blood pressure). Use of the Impella CP, intraprocedural complications, periprocedural complications and in-hospital mortality were all more common amongst the prolonged MCS group. Prolonged MCS was associated with increased rates of major adverse cardiovascular and cerebrovascular events, cardiovascular death, and all-cause mortality at 90-day follow-up. Patients receiving prolonged MCS after Impella-supported HR-PCI presented with more ACS, reduced EF and less favourable haemodynamics. Additionally, they were more likely to experience intraprocedural and periprocedural complications as well as increased in-hospital and post-discharge mortality.

Outcomes after heart transplantation in patients who have undergone a bridge-to-bridge strategy

ObjectivesWe compared posttransplant outcomes between patients bridged from temporary mechanical circulatory support to durable left ventricular assist device before transplant (bridge-to-bridge [BTB] strategy) and patients bridged from temporary mechanical circulatory support directly to transplant (bridge-to-transplant [BTT] strategy). MethodsWe identified adult heart transplant recipients in the Organ Procurement and Transplantation Network database between 2005 and 2020 who were supported with extracorporeal membrane oxygenation, intra-aortic balloon pump, or temporary ventricular assist device as a BTB or BTT strategy. Kaplan-Meier survival analysis and Cox regressions were used to assess 1-year, 5-year, and 10-year survival. Posttransplant length of stay and complications were compared as secondary outcomes. ResultsIn total, 201 extracorporeal membrane oxygenation (61 BTB, 140 BTT), 1385 intra-aortic balloon pump (460 BTB, 925 BTT), and 234 temporary ventricular assist device (75 BTB, 159 BTT) patients were identified. For patients supported with extracorporeal membrane oxygenation, intra-aortic balloon pump, or temporary ventricular assist device, there were no differences in survival between BTB and BTT at 1 and 5 years posttransplant, as well as 10 years posttransplant even after adjusting for baseline characteristics. The extracorporeal membrane oxygenation BTB group had greater rates of acute rejection (32.8% vs 13.6%; P = .002) and lower rates of dialysis (1.6% vs 21.4%; P < .001). For intra-aortic balloon pump and temporary ventricular assist device patients, there were no differences in posttransplant length of stay, acute rejection, airway compromise, stroke, dialysis, or pacemaker insertion between BTB and BTT recipients. ConclusionsBTB patients have similar short- and midterm posttransplant survival as BTT patients. Future studies should continue to investigate the tradeoff between prolonged temporary mechanical circulatory support versus transitioning to durable mechanical circulatory support.

Ultra-prolonged Intra-aortic Balloon Pump Support Via Sheathless Femoral Access

<h3>Introduction</h3> Intra-aortic balloon pump (IABP) insertion via axillary access is increasingly utilized given convenience to the patient. We present a case of innovative femoral IABP access that allowed for prolonged mechanical circulatory support and patient rehabilitation. <h3>Case presentation</h3> A 20s-year-old gentleman with non-ischemic cardiomyopathy, listed for heart transplantation on continuous dobutamine infusion, was admitted in ambulatory cardiogenic shock state. A left axillary artery 50 mL IABP was inserted to facilitate physical and nutritional rehabilitation. Over the subsequent 23 days, he encountered three IABP malfunction events requiring device replacement. Examination of the extracted devices demonstrated recurrent kinking in the proximal IABP shaft past the exit point from the axillary arteriotomy sheath. As such, it was felt that the axillary artery anatomy was preclusive of stable IABP function and a 50 mL IABP was inserted via the right femoral artery. We used the routine modified Seldinger method and ultrasound guidance to obtain arterial access. The IABP was inserted without an access sheath and secured using 3M™ Ioban 2™ Antimicrobial drape. The patient continued to respond well to IABP support hemodynamically, however, transplantation was delayed due to patient and donor pool characteristics. On hospital day 32, our cardiac physical therapy team began utilizing a tilt table for therapy to help the patient stand. Ambulation when then progressed to ambulating up to 3,500 feet in a single session by day 64 after femoral IABP insertion (figure 1). We observed no access site bleeding, infection, or ischemic events. The patient was offered durable mechanical support as a bridge to transplantation but decided to continue temporary support until he successfully underwent orthotopic heart transplantation on hospital day 125. <h3>Conclusion</h3> Our case is unique in being able to achieve ultra-long support safely via sheathless femoral arterial access while continuing to ambulate the patient daily to prevent deconditioning. This access approach may decrease complication risk and expand the use of this traditionally short-term insertion technique, for more long-term support.

Percutaneous Left Axillary Artery Placement of Intra-Aortic Balloon Pump in Advanced Heart Failure Patients

ObjectivesThis study presents the largest clinical experience of percutaneously placed axillary intra-aortic balloon pump (IABP) in patients with advanced heart failure. BackgroundTransfemoral placement of IABP limits mobility and recuperation in patients who need prolonged support. We had previously reported a novel percutaneous method of IABP placement in the axillary artery and now present our expanded experience with this technique. MethodsWe performed a retrospective chart review of patients with advanced heart failure with percutaneous axillary IABP placement from November 2007 to June 2018 at Houston Methodist Hospital. We defined successful cardiac replacement therapy as heart transplant or left ventricular assist device implantation. We compared patients who had successful cardiac replacement with those who died and those who needed unplanned escalation of mechanical circulatory support. ResultsOf the 195 patients identified, 133 (68%) underwent successful cardiac replacement (120 transplants and 13 left ventricular assist device) as planned. End-organ function improved on IABP support in patients bridged to next therapy. There were 16 patients that died while on IABP support and 18 needed escalation of support. Higher right atrial/wedge ratio, higher right atrial pressure, smaller left ventricular end diastolic dimension, and ischemic cardiomyopathy were associated with death on the IABP in multivariate analysis. Post-transplant and post left ventricular assist device survival for those bridged successfully was 87% and 62%, respectively. Although bedside repositioning was frequent, 37% needed replacement for malfunction. Vascular complications occurred in a minority. ConclusionsPercutaneous axillary approach for IABP placement is a feasible strategy for prolonged mechanical circulatory support in patients with advanced heart failure.

SPECIAL ASPECTS OF IMPLANTATION OF A HEART PUMP SUPPORT SYSTEM AVK-N AS A «BRIDGE» TO HEART TRANSPLANTATION

Aim:to develop an optimal surgical tactic for implantation of “AVK-N” system as a “bridge” to heart transplantation.Materials and methods.17 patients were included. They were operated in the period from 2012 to October 2017 in Federal State Budgetary Institution «V.I. Shumakov National Medical Research Center of Transplantology and Artifi cial Organs». A tiny implantable system «Portable device for assisting cardiac circulation» (AVK-N; Russia) was used for replacing the pumping function of the left ventricle. All patients were examined according to the program of potential recipients for heart transplantation, before the applying of prolonged mechanical circulatory support. Among the operated patients there were 16 (94.1%) men and 1 (5.9%) woman, the average age was 52.64 ± 10.56 (from 33 to 67 years). All patients had congestive heart failure III–IV functional class according to NYHA, refractory to optimal drug therapy. Heart failure was triggered by dilated cardiomyopathy in 12 (70,58%) cases, and by postinfarction systolic dysfunction of the left ventricle in 5 (29,42%). Implantation of «AVK-N» system was performed to potential recipients of the donor heart with terminal stage of CHF with a decrease in LV ejection fraction up to 10%.Results.As a result of this study there were developed several technological aspects facilitating the subsequent heart transplantation.Conclusion.Our experience in optimizing the surgical tactics of the “AVK-N” system implantation as a bridge to heart transplantation, demonstrated the possibility and safety of its active use in both patients with terminal heart failure on the waiting list of heart transplantation and patients having temporary contraindications to HTX.

Maximum level of mobility with axillary deployment of the Impella 5.0 is associated with improved survival.

Mobility is an important prognostic indicator for patients with cardiogenic shock. No studies have quantified peak mobility for patients with cardiogenic shock who are supported with the Impella 5.0 acute mechanical circulatory support device. The purpose of our study was to evaluate mobility levels among patients with cardiogenic shock being treated with an axillary Impella 5.0 pump. We retrospectively analyzed data from 19 patients receiving an Impella 5.0 device for cardiogenic shock at our institution from 2013 to 2016. We used the Johns Hopkins Highest Level of Mobility Scale to quantify maximum mobility level achieved during active Impella 5.0 support. Higher scores on a scale of 1-8 indicated more mobility. Activity Measure for Post Acute Care Scores were quantified for each patient to assess activity limitations, with a maximum score 24. The mean age of the total cohort was 60 ± 12 years, and the mean left ventricular ejection fraction was 16% ± 6%. In-hospital mortality was 47% (n = 9). Of the 19 Impella 5.0 implants, 10 survived, 6 died from withdrawal of care, and 3 died from worsening heart failure/cardiogenic shock. Similar rates of mobilization during the time of Impella implant were seen between groups. Compared to non-survivors, survivors achieved a higher maximum Johns Hopkins Highest Level of Mobility level, but similar Activity Measure for Post Acute Care scores. In conclusion, maximum mobility after Impella 5.0 implantation may be associated with improved survival. The clinical utility of exercise as a therapeutic intervention for patients requiring prolonged acute mechanical circulatory support requires further study.

Characterizing Predictors and Severity of Vasoplegia Syndrome After Heart Transplantation

Vasoplegia is characterized as a severe vasodilatory shock after cardiac surgery, and can be associated with substantial morbidity. Increased systemic inflammation and endothelial dysfunction, often related to prolonged cardiopulmonary bypass times, anesthesia, or mechanical circulatory support have been shown to be associated with the development of vasoplegia. We sought to identify risk factors and the impact of various degrees of vasoplegia after heart transplantation. A retrospective review was conducted of 244 consecutive patients who underwent heart transplantation over a 3-year period. Patients were divided into three groups: no vasoplegia, mild vasoplegia (requiring one vasopressor), and moderate/severe vasoplegia (more than two vasopressors). One-year survival, freedom from rejection, and postoperative complication rates were assessed. Risk factors for vasoplegia subgroups were retrospectively identified. Vasoplegia syndrome was observed in 34.3% of patients after heart transplantation (mild, 74.1%; moderate/severe, 25.9%). Cardiopulmonary bypass time was significantly longer and pretransplant creatinine was significantly higher in the moderate/severe vasoplegia group. There was a strong trend toward greater use of mechanical circulatory support among moderate/severe vasoplegia patients compared with mild and no vasoplegia patients. After heart transplantation, 1-year survival, freedom from rejection, and need for hemodialysis were not significantly different between groups. Vasoplegia syndrome is common after heart transplantation. Risk factors for increased severity include longer cardiopulmonary bypass times and elevated preoperative creatinine. Although higher rates of mortality or graft rejection were not detected, vasoplegia was associated with prolonged intubation, greater blood product usage, and lengthened hospital stay. Further studies involving larger cohorts are warranted.

Fin de vie : une nouvelle loi

Vasoplegia is characterized as a severe vasodilatory shock after cardiac surgery, and can be associated with substantial morbidity. Increased systemic inflammation and endothelial dysfunction, often related to prolonged cardiopulmonary bypass times, anesthesia, or mechanical circulatory support have been shown to be associated with the development of vasoplegia. We sought to identify risk factors and the impact of various degrees of vasoplegia after heart transplantation.A retrospective review was conducted of 244 consecutive patients who underwent heart transplantation over a 3-year period. Patients were divided into three groups: no vasoplegia, mild vasoplegia (requiring one vasopressor), and moderate/severe vasoplegia (more than two vasopressors). One-year survival, freedom from rejection, and postoperative complication rates were assessed. Risk factors for vasoplegia subgroups were retrospectively identified.Vasoplegia syndrome was observed in 34.3% of patients after heart transplantation (mild, 74.1%; moderate/severe, 25.9%). Cardiopulmonary bypass time was significantly longer and pretransplant creatinine was significantly higher in the moderate/severe vasoplegia group. There was a strong trend toward greater use of mechanical circulatory support among moderate/severe vasoplegia patients compared with mild and no vasoplegia patients. After heart transplantation, 1-year survival, freedom from rejection, and need for hemodialysis were not significantly different between groups.Vasoplegia syndrome is common after heart transplantation. Risk factors for increased severity include longer cardiopulmonary bypass times and elevated preoperative creatinine. Although higher rates of mortality or graft rejection were not detected, vasoplegia was associated with prolonged intubation, greater blood product usage, and lengthened hospital stay. Further studies involving larger cohorts are warranted.

HEART TRANSPLANTATION IN PATIENTS WITH PREVIOUS OPEN HEART SURGERY

Heart Transplantation (HTx) to date remains the most effective and radical method of treatment of patients with end-stage heart failure. The defi cit of donor hearts is forcing to resort increasingly to the use of different longterm mechanical circulatory support systems, including as a «bridge» to the follow-up HTx. According to the ISHLT Registry the number of recipients underwent cardiopulmonary bypass surgery increased from 40% in the period from 2004 to 2008 to 49.6% for the period from 2009 to 2015. HTx performed in repeated patients, on the one hand, involves considerable technical diffi culties and high risks; on the other hand, there is often no alternative medical intervention to HTx, and if not dictated by absolute contradictions the denial of the surgery is equivalent to 100% mortality. This review summarizes the results of a number of published studies aimed at understanding the immediate and late results of HTx in patients, previously underwent open heart surgery. The effect of resternotomy during HTx and that of the specifi c features associated with its implementation in recipients previously operated on open heart, and its effects on the immediate and long-term survival were considered in this review. Results of studies analyzing the risk factors for perioperative complications in repeated recipients were also demonstrated. Separately, HTx risks after implantation of prolonged mechanical circulatory support systems were examined. The literature does not allow to clearly defi ning the impact factor of earlier performed open heart surgery on the course of perioperative period and on the prognosis of survival in recipients who underwent HTx. On the other hand, subject to the regular fl ow of HTx and the perioperative period the risks in this clinical situation are justifi ed as a long-term prognosis of recipients previously conducted open heart surgery and are comparable to those of patients who underwent primary HTx. Studies cited in the review may have important clinical applications, because they outline the range of problems and possible solutions in the performance of the HTx in recipients previously operated on open heart. This knowledge can facilitate the decision making process with regard to the opportunities and risks of the implementation of HTx. Given the uniqueness of each of the recipient and the donor, it is required to make a personalized approach to the question of the possible risks and to the preventive measures to reduce those risks in any given clinical situation.

Management of children with dilated cardiomyopathy in The Netherlands: Implications of a low early transplantation rate

The policy for listing and transplant for children with dilated cardiomyopathy (DCM) in The Netherlands has been conservative because of low donor availability. The effects of this policy on outcome are reported. This was a multicenter, nationwide study performed in 148 children with DCM. The primary outcome was death or heart transplant. Overall, 43 patients (29%) died or were transplanted. Within 1 year of diagnosis, 21 patients died, and only 4 underwent transplantation (3 on mechanical circulatory support). The 1-year survival was 85% (95% confidence interval [CI] = 79-91), and 5-year survival was 84% (95% CI = 78-90). Transplantation-free survival at 1 year was 82% (95% CI = 75-88) and at 5 years was 72% (95% CI = 64-80). Within 1 year of diagnosis, with death as the main end-point (21 of 25, 84%), intensive care unit admission (hazard ratio = 2.6, p = 0.05) and mechanical circulatory support (hazard ratio = 3.2, p = 0.03) were risk factors (multivariable Cox analysis); inotropic support was longer in patients reaching an end-point. At >1 year after diagnosis, with transplantation as the main end-point (15 of 18, 83%), age >6 years (hazard ratio = 6.1, p = 0.02) was a risk factor. There were 56 (38%) children who recovered, 50% within 1 year of diagnosis. Recovery was associated with younger age; was similar in patients with myocarditis (43%) and idiopathic disease (41%); and was similar in patients initially admitted to the intensive care unit, admitted to the ward, or treated as outpatients. The transplantation rate in our cohort in the first year was low, with 1-year and 5-year survival rates similar to other cohorts. Our results suggest that a conservative approach to list children for transplantation early after presentation may be justifiable except for patients with prolonged intensive care unit or mechanical circulatory support.

Left ventricular assist devices for prolonged mechanical circulatory support: a change of paradigm for end-stage heart failure

La transplantation cardiaque est une option therapeutique envisageable seulement pour un nombre limite de patients en insuffisance cardiaque terminale. L’assistance circulatoire mecanique de longue duree, en alternative a la transplantation, est une nouvelle option prometteuse. L’etude REMATCH a montre que l’implantation d’un dispositif d’assistance ventriculaire gauche pulsatile permettait d’ameliorer la survie comparativement a l’optimisation du traitement medical chez des patients non eligibles a la transplantation. L’avenement de nouveaux dispositifs d’assistance ventriculaire gauche a debit continu, plus petits que les precedents, a significativement ameliore la survie a 1 et 2 ans sous assistance et les capacites fonctionnelles et la qualite de vie des patients. Les progres technologiques a venir vont contribuer a reduire la morbidite liee a ces dispositifs et permettront probablement d’envisager leur implantation a des stades d’insuffisance cardiaque moins avancee.

Management of Aortic Insufficiency in the Continuous Flow Left Ventricular Assist Device Population

With the current generation of continuous-flow (CF) left ventricular assist devices (LVADs), patients are able to be supported for longer periods of time. As a result, there has been increasing focus on long-term complications from prolonged mechanical circulatory support, such as acquired aortic insufficiency (AI). In the presence of an LVAD, AI leads to a blind circulatory loop, with a portion of LVAD output regurgitating through the aortic valve (AV) into the left ventricle and back again through the device, limiting effective forward flow and ultimately leading to organ malperfusion and increased left ventricular diastolic pressures. The AV also experiences abnormal biomechanics as a result of limited valve opening in the presence of a CF LVAD. Increased shear stress, elevated transvalvular pressure gradients, and decreased valve open time all contribute to acquired AI. The prognosis of moderate to severe AI in LVAD patients is generally poor and leads to a higher rate of AV replacement and potentially reduced survival. However, there are no evidence-based guidelines for management of this challenging population. In severe AI, experts generally advocate AV replacement or repair, while lesser degrees of AI can be managed medically and/or with adjustments in pump parameters.

Recurrent or Prolonged Mechanical Circulatory Support

Remarkable outcomes have been reported after prolonged mechanical circulatory support in the pediatric population, but there is yet no clear delineation of the duration beyond which supporting a child becomes futile. The likelihood of survival in patients supported on extracorporeal membrane oxygenation for respiratory failure decreases with the length of support. However, extracorporeal membrane oxygenation can be successfully used in these patients for long periods (weeks to months) provided adequate support is maintained without complications. This is not the case with cardiac failure and mechanical circulatory support.Extracorporeal membrane oxygenation is usually the initial form of mechanical circulatory support used in patients with primary refractory myocardial dysfunction. There is evidence and consensus that if the patient shows no signs of recovery after a maximum duration of 2 weeks, he or she should be transitioned to a ventricular assist device, which allows prolonged support. In post-cardiac surgery patients, survival is only anecdotal beyond 12 days of extracorporeal membrane oxygenation support, and myocardial recovery is exceptionally rare after this time period unless new diagnoses and management strategies are formulated.Repeat extracorporeal membrane oxygenation should generally not be offered to patients unless it is established that support was withdrawn prematurely or a new intervention is planned. Repeat extracorporeal membrane oxygenation may achieve some improvement in early survival, but the long-term outcomes of survivors are so poor that these attempts cannot be generally recommended unless organ transplantation is an option.

Prolonged Mechanical Circulatory Support – 1000 Days with a Left Ventricular Assist Device

Purpose Ventricular assist devices (LVADs) are used for bridge to heart transplantation (BTR) and long term destination therapy (DT) for patients with end stage heart failure. Due to the growing number of patients with terminal heart failure and a decrease in suitable donor organs, timespans on mechanical circulatory support (MCS) of patients are continuously increasing. Methods and Materials Since 2006 283 patients received LVAD support with HeartMate II (HM2; n=160), Duraheart (DUH; n=74) and Ventrassist (VA; n=46). We analysed 34 patients (12.01%) who were supported with a device for more than 1000 days. The patients were divided into two groups, DT (n=11: VA n=5, HM2 n=4, DUH n=2) and BTR (n=22: HM2 n=9; VA n=7; DUH n=6). Patients were analysed retrospectively with regard to neurologic, infectious and gastrointestinal complications. Results Mean duration of support of all patients was 1278 days. 7 out of 34 patients, were succesfully transplanted, 4 died and 1 was successfully weaned and 22 patients are still on support. Major complications during support were driveline infections (n=7), gastrointestinal bleedings (n=7), technical failure (n=6/cable breakage n=4), neurologic events (n=6). First hospitilization after inital discharge home was after 9.8 months, the mean frequency of hospitilizations being 4.1 times. The overall mean duration of hospital stay was 65 days. Reasons for high urgency transplantation were neurologic complications (n=3; TIA,intracerebral bleeding, stroke), cable breakage (n=3) and hemolysis (n=1). Five patients expired (min. 1063days/max. 1392days) under support because of malignant tumors (n=2), late right heart failure (n=1), intracerebral bleeding (n=1) and one patient becuase of primary graft failure post heart transplantation. Conclusions In the light of substantial donor organ shortage and the growing number of heart failure patients prolonged MCS has become a more frequent treatment modality. Here we show that this can be achieved with acceptable longterm results.

Successful mechanical circulatory support for 251 days in a child with intermittent severe neutropenia due to Barth syndrome

Barth syndrome is an X-linked recessive disorder that is characterized by cardiomyopathy, variable neutropenia, skeletal myopathy, growth delay, and organic aciduria. The cardiac involvement typically results in a high risk of severe heart failure in infancy or early childhood. While Berlin Heart EXCOR is widely accepted as ventricular assistance in pediatric patients with end-stage cardiac failure, infections remain a frequent and potentially severe complication. Therefore, the extended use of the device in the setting of intermittent or severe neutropenia is challenging. We present the case of a three-yr child with Barth syndrome who was bridged successfully to transplant with a Berlin Heart EXCOR assist device for eight months (251 days) without major infectious complication, despite several episodes of severe neutropenia. This case demonstrates that prolonged mechanical circulatory support for a patient with neutropenia is feasible without important morbidity, with careful monitoring and a multidisciplinary approach. G-CSF provides an excellent support in managing neutropenia.

795 Evidence for Restoration of Glucose Metabolism in Failing Myocardium Following Prolonged Mechanical Circulatory Support

795 Evidence for Restoration of Glucose Metabolism in Failing Myocardium Following Prolonged Mechanical Circulatory Support

A large postoperative left ventricular hemorrhagic contusion and management by prolonged mechanical circulatory support: a case report

Dear Editor, We experienced a postoperative traumatic left ventricular hematoma that was incidentally found after establishment of rescue mechanical circulatory support (MCS) following sudden postoperative circulatory collapse in the cardiac intensive care unit (CICU). The patient successfully recovered with aggressive and prolonged mechanical circulatory support. We report this case to share a worrisome clinical experience in an intensive care unit. The 4-month-old patient weighing 6.6 kg diagnosed with tetralogy of Fallot and a small secundum atrial septal defect underwent successful total correction in the operation room. However, when he arrived at the cardiac intensive care unit (CICU), sudden bradyarrhythmia developed, leading to acute circulatory collapse. At that moment, we performed open cardiopulmonary resuscitation and established rescue extracorporeal membrane oxygenation (ECMO, Bio-Medicus , Eden Prairie, MN; PHISIO oxygenator, Dideco, Mirandola, Italy). On the 3rd postoperative day, bedside echocardiography showed an unexplained huge hematoma, which was suspected to abut the posterior wall of the left ventricle (LV) in the pericardial space in the first place. On the same day, however, while performing mediastinal irrigation to control bleeding in the operating room, the suspected intrapericardial mass was confirmed to be a swollen hemorrhagic contusion of the posterior wall of the left ventricle, which was also demonstrated in follow-up cardiac computed tomography (Fig. 1). As diffuse oozing from the LV was occurring, packed Gelfoam with thrombin was applied on the LV wall, and massive mediastinal irrigation followed. For anticoagulation, initially heparin was titrated to maintain an ACT around 160 s, followed by exclusion of heparin since LV contusion was confirmed. Packed RBCs and platelets were transfused to achieve Hb [10 g/dl and platelet counts [80,000/mm. On the 4th postoperative day, the oxygenator was changed to a new one because a thrombus had formed in the old one. The patient was weaned from ECMO on the 7th postoperative day, and the divided sternal ends were gradually pulled to the opposite side with a pair of traction strings, accommodating the huge LV. The sternal wound was finally closed on the 14th postoperative day. The patient was able to be discharged with a little motor hypotonia and then completed rehabilitation therapy. The hemorrhagic contusion of the myocardium that developed during ECMO setup was very unusual. In our case, we suspect that the huge contusional hemorrhage of the LV resulted from the procedures used during open cardiac massage and ECMO cannulation. Hemorrhagic problems and bleeding control are always cumbersome issues during ECMO setup [1, 2]. In this case in particular, the contusional wound of the myocardium kept oozing diffusely. However, packing the thrombogenic agent with Gelfoam and maintaining low ACT [2] were relatively effective and sufficient in this puzzling situation. In general, postoperative myocardial edema is decompressed by opening the sternum and covering the wound with a Gore-Tex patch or other materials [3]. However, in our case, the LV was too large to apply

The last to die is hope: Prolonged mechanical circulatory support with a Novacor left ventricular assist device as a bridge to transplantation

J Thorac Cardiovasc Surg 2003;125:417-8

Differences in Length of Stay between Coronary Bypass and Valve Procedures

Emphasis on cost reduction, national standardization of medical care, and quality improvement initiatives have led to reduced postoperative hospital stays after cardiac surgery. The present study was designed to verify the observation that valve patients have longer lengths of stay than bypass patients and to identify possible reasons. The inpatient records of 26 consecutive patients who underwent valve procedures at our institution were reviewed and compared with the records of 25 consecutive coronary bypass patients. Patients whose postoperative stays were longer than 2 weeks were considered outliers and were excluded from further review. A total of 51 records were reviewed. There were no in-hospital deaths. Five patients in the valve group and two in the bypass group were excluded because of lengths of stay exceeding 14 days. The mean length of stay for the valve procedure group was 7.7 +/- 2.1 days, vs. 5.7 +/- 1.5 days for the coronary bypass group (p = 0.001). There were no reoperative procedures in either group, and the number of emergency procedures was higher in the bypass group. Both groups were similar with respect to age and sex. The frequencies of associated pulmonary disease and malnutrition were similar. Bypass patients had a higher incidence of vascular disease and/or renal disease. Sixty percent of valve procedures were complex operations. Valve patients had a higher incidence of cardiopulmonary bypass times exceeding 3 hours and more postoperative bleeding complications. Although not statistically significant, valve procedure patients were more likely to require prolonged mechanical ventilatory and circulatory support postoperatively. The frequencies of thrombotic complications, neurological complications, and nosocomial infections were similar for both groups. Postoperatively, more valve patients had atrial fibrillation, and all of them received anticoagulation. Multivariate analysis revealed only two factors to be significant with regard to length of stay: valvular surgery and the duration of postoperative ventilatory support. Cardiac valve procedures are associated with prolonged lengths of stay compared with isolated coronary bypass procedures. Despite recent trends toward earlier operation, valve patients tended to present with advanced disease. More than half of the valve patients required complex surgical procedures. This is reflected in longer bypass times, increased bleeding complications, and more postoperative support. The proportion of valvular surgery patients should be considered when analyzing lengths of stay for cardiac surgery cohorts.

SYMPATHOINHIBITION IN CRITICAL ILLNESS DURING MECHANICAL CIRCULATORY SUPPORT

In variability of systemic blood pressure, the power spectral component with high frequency (0.15 to 0.4 Hz) is usually regarded as a marker of the para-sympathetic activity, and the component with low frequency (0.04 to 0.15 Hz) has been related to the sympathetic activity. Purpose: To evaluate the applicability of power spectral analysis of systemic blood pressure in estimating the state of patients after cardiac surgery. Methods: Hemodynamic data were sampled every 2 hours at 100 Hz for 6 minitutes in patients undergone cardiac surgery. Power spectral analysis of systemic arterial pressure signals was carried out. A trend of changes in the spectral components of systemic arterial pressure were obsereved in the patients with mechanical circulatory support (group M; n=9) for low cardiac output syndrome (LOS) and in control patients without mechanical circulatory support (group N; n=9). Results: The power spectral component with low frequency have the tendency to increase in both groups except 3 patients in group M, and the increment of group M is behind that of group N. Sustained low values in the low frequency component of systemic arterial pressure signals in the 3 patients were related to prolonged mechanical circulatory support, and 2 patients among them were expired consequently. Conclusion: Recovery from the postoperative sympathoinhibitory state in patients with mechanical circulatory support significantly delayed comparing with that in patients without the support. Power spectral analysis of systemic arterial pressure provides a reasonable tool to evaluate the severity of patients' condition regarding the activity of autonomic nervous system which regulates the heart and blood vessels.