Severe Ischemic Cardiomyopathy Research Articles

Coronary artery bypass grafting vs. percutaneous coronary intervention in severe ischaemic cardiomyopathy: long-term survival.

The optimal revascularization strategy in patients with ischaemic cardiomyopathy remains unclear with no contemporary randomized trial data to guide clinical practice. This study aims to assess long-term survival in patients with severe ischaemic cardiomyopathy revascularized by either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons and Melbourne Interventional Group registries (from January 2005 to 2018), patients with severe ischaemic cardiomyopathy [left ventricular ejection fraction (LVEF) <35%] undergoing PCI or isolated CABG were included in the analysis. Those with ST-elevation myocardial infarction and cardiogenic shock were excluded. The primary outcome was long-term National Death Index-linked mortality up to 10 years following revascularization. Risk adjustment was performed to estimate the average treatment effect using propensity score analysis with inverse probability of treatment weighting (IPTW). A total of 2042 patients were included, of whom 1451 patients were treated by CABG and 591 by PCI. Inverse probability of treatment weighting-adjusted demographics, procedural indication, coronary artery disease extent, and LVEF were well balanced between the two patient groups. After risk adjustment, patients treated by CABG compared with those treated by PCI experienced reduced long-term mortality [adjusted hazard ratio 0.59, 95% confidence interval (CI) 0.45-0.79, P = .001] over a median follow-up period of 4.0 (inter-quartile range 2.2-6.8) years. There was no difference between the groups in terms of in-hospital mortality [adjusted odds ratio (aOR) 1.42, 95% CI 0.41-4.96, P = .58], but there was an increased risk of peri-procedural stroke (aOR 19.6, 95% CI 4.21-91.6, P < .001) and increased length of hospital stay (exponentiated coefficient 3.58, 95% CI 3.00-4.28, P < .001) in patients treated with CABG. In this multi-centre IPTW analysis, patients with severe ischaemic cardiomyopathy undergoing revascularization by CABG rather than PCI showed improved long-term survival. However, future randomized controlled trials are needed to confirm the effect of any such benefits.

The correlation between cardiac magnetic resonance imaging and echocardiography in patients with severe ischaemic cardiomyopathy

Abstract Background Left ventricular ejection fraction is the single metric that guides therapeutic decision-making, risk stratification and prognosis in patients with severely impaired systolic function. Although cardiac magnetic resonance imaging (CMR) is the current reference standard for quantification of ventricular volume and function, echocardiography is used more often as it is more widely available and less expensive.(1) Aims To evaluate the correlation between CMR and echocardiography in quantifying left ventricular (LV) volume and function and to determine whether these measurements are associated with clinical outcomes in patients with severe ischemic cardiomyopathy (ICM). Methods Participants recruited to the REVIVED-BCIS2 trial who had undergone baseline CMR or echocardiography were included in this analysis. All scans were analyzed in blinded core laboratories as previously reported.(2,3) All volumes were indexed to body surface area. Spearman correlation, Bland Altman analysis and coverage probability methods were performed to assess the correlation between the two modalities. A Cox proportional hazards model was used to assess the association between imaging metrics and the primary outcome, a composite of all-cause death and aborted sudden death. A sensitivity analysis was conducted a priori, restricted to patients undergoing both scans within 60 days of each other. Results A total of 373 participants with paired imaging data were included: mean age 69±9 years, 87% male, BMI 28±5. A moderate correlation was detected for volume measurements between the modalities (end diastolic volume index (EDVI) r=0.66 end systolic volume index (ESVI) r=0.68), with a weaker correlation for LV ejection fraction (EF) (r=0.41). Bland-Altman plots showed moderate agreement in LVEF measurements (Table 1). The sensitivity analysis included 199 patients, and showed similar results (EDVI r=0.72, ESVI r=0.73 LVEF r=0.43, all p&amp;lt;0.000). Only 7.5% of the paired LVEF measurements were within 5% of each other. 30% of participants were misclassified by echocardiography as having an LVEF&amp;gt;35%. (Figure 1) CMR ESVI was associated with the occurrence of the primary outcome (HR 1.05 per 10ml increment, 95% CI 1.00-1.10) however echo ESVI (HR 1.05 per 10ml increment 95% CI 0.99 – 1.10) and all other imaging metrics were not. Conclusion Left ventricular volumes and ejection fraction on CMR and echocardiography were only modestly correlated in this population with severe ICM. When using the binary EF threshold of 35% that is commonly used to select patients of implantable defibrillator therapy, almost a third of patients at risk would have been missed by echocardiography alone. The additional insights provided by CMR, including scar burden, further support preferential use of this modality in the assessment such patients.

Surgical Management of Aortic Root Thrombus in Acute Severe Ischaemic Cardiomyopathy Patient Supported With Continuous-Flow Left Ventricular Assist Device

Surgical Management of Aortic Root Thrombus in Acute Severe Ischaemic Cardiomyopathy Patient Supported With Continuous-Flow Left Ventricular Assist Device

Nursing cooperation in orthotopic heart and liver transplantation-A case report

Nursing cooperation in orthotopic heart and liver transplantation Patients with ischemic cardiomyopathy and decompensation of alcoholic liver cirrhosis. To summarize the main points of nursing cooperation for a case of alcoholic liver cirrhosis with decompensated liver function and severe ischemic cardiomyopathy undergoing orthotopic heart-liver transplantation. It is proposed that the nurses in the operating room should have a detailed understanding of the patient’s relevant conditions and special requirements before the operation, and participate in the multidisciplinary professional team to formulate possible emergency plans

Recovery from severe ischemic cardiomyopathy after high-risk percutaneous coronary intervention facilitated by levosimendan infusion and Impella CP support and prolonged use of a wearable defibrillator vest.

Recovery from severe ischemic cardiomyopathy after high-risk percutaneous coronary intervention facilitated by levosimendan infusion and Impella CP support and prolonged use of a wearable defibrillator vest.

Scar characterisation to predict arrhythmia and death in ischaemic cardiomyopathy: insights from the REVIVED trial

Abstract Background Ischaemic cardiomyopathy continues to have unacceptably high mortality despite contemporary medical and device therapy (1). Ventricular arrhythmias are a leading cause of both death and morbidity in this population. Current guidelines recommend implantable cardioverter defibrillator (ICD) implantation in patients with a left ventricular ejection fraction (LVEF) below 35% but many who meet criteria never receive a therapy and there is a persistent sudden cardiac death risk in those who do not. Scar characteristics are not currently included in risk stratification algorithms, however both volume and entropy, a measure of myocardial heterogeneity, have been linked to arrhythmic risk. Purpose To assess whether left ventricular scar burden and morphology predicts fatal and non-fatal arrhythmia, independent of LVEF in severe ischaemic cardiomyopathy. Methods REVIVED-BCIS2 was a prospective, randomized controlled trial, which recruited 700 patients from 40 centres across the United Kingdom (1). Trial eligibility required the presence of ≥4 dysfunctional but viable myocardial segments; the majority of patients had viability assessed by cardiac magnetic resonance imaging (CMR). Semi-quantitative CMR scar burden was determined through consensus by two CMR experts in a blinded core laboratory. Scar morphology was further characterised by left ventricular entropy measured using novel dedicated software (TexRAD Ltd., Feedback plc, UK). The primary outcome was the composite of all-cause death and aborted sudden death (in turn, defined as appropriate ICD therapy or resuscitated cardiac arrest). Cox proportional hazard models were used to determine the effect of scar burden and entropy on clinical outcomes, adjusted for baseline LVEF, extent of coronary disease, type of implantable device and randomized treatment. Results Four hundred and ninety one patients underwent viability assessment by CMR and 478 were included in this analysis (Figure 1). Mean age was 69 ± 9; median follow up duration was 3.3 [2.3-4.9] years. By the end of trial follow up, 257/478 had a device in situ (CRT-D 99, ICD 147, CRT-P 11). The primary outcome occurred in 182 patients (38.1%). Each 10% increase in scar volume was associated with a 24% increase in the incidence of the primary outcome (adjusted HR per 10% 1.24, 95% CI: 1.11 to 1.39, p = 0.0002)(Figure 2). LVEF at baseline was not predictive (adjusted HR per 5% increase 0.94, 95% CI 0.86 – 1.02, p = 0.13). The relationship between LV entropy and outcomes will be presented at ESC. Conclusions In patients with severe ischaemic cardiomyopathy, scar volume was predictive of death and potentially fatal arrhythmias. Left ventricular ejection fraction was not a significant predictor in this cohort. Scar characteristics should form an integral part of risk stratification.Consort diagramPrimary outcome by scar burden

Cardioprotective potential of exosomes derived from blood outgrowth endothelial cells in ischemic cardiomyopathy

Abstract Introduction Blood outgrowth endothelial cell (BOEC)-derived exosomes can effectively induce vascular network formation in vitro and mediate therapeutic neovascularization in a skin wound healing model. We hypothesized that BOEC-derived exosomes can enhance myocardial repair in mice after ischemia-reperfusion (I/R) injury. Methods BOECs were isolated and culture-expanded from peripheral blood of patients with severe ischemic cardiomyopathy (ICMP) in normoxic and hypoxic (1% O2) conditions. Exosomes were isolated from the medium by differential ultracentrifugation, and their size, number, and surface markers were determined by nano tracking analysis (NTA) and immunoblot analysis. Myocardial infarction (MI) was induced via transient LAD ligation for 60 min followed by reperfusion. BOEC-derived exosomes and were resuspended in small fractions (120x10^8 particles per 10 µl) 2.5 µl 4 aliquots were injected under direct vision into the epicardial wall of the peri-infarct region. One month later, left ventricular (LV) structure and function were analyzed using a 7T Bruckner MRI with commercial software Segment in mice that received exosome injections or placebo injections (n=10 and n=8, respectively). Results Quantification of exosomes by NTA showed higher concentrations in the medium of BOECs cultured in hypoxia. Immunoblot analysis confirmed robust expression of exosome markers TSG101 and Flotilin-1. One month after intramyocardial exosome injections, heart rate, LV volumes or LV ejection fraction were similar between mice receiving myocardial exosomes injections (n=10) in the border zone as compared to those receiving placebo (n=8). However, in vivo exosome transfer mediated favorable structural remodeling after MI with lower LV mass indices (p=0.01) and better preserved regional wall thickness in all 4 segments receiving exosomes aliquots (p&amp;lt;0.05) (Figure). Conclusions Our results suggest that BOEC-derived exosomes have favorable post-infarction myocardial structural remodeling. Exosomes may constitute an attractive cell-free therapeutic modality.Figure

Abstract 14858: Revascularization Shows Beneficial Cardiovascular Outcomes in Severe Ischemic Cardiomyopathy: A Systematic Review and Meta-Analysis

Introduction: Revascularization approach is historically prioritized over optimal medical therapy (OMT) for patients with severe stable ischemic cardiomyopathy (ICM) with ejection fraction &lt; 35%. However, with advancement in OMT, recent studies have shown similar cardiovascular outcomes between the two strategies. Herein, we present a systematic review and meta-analysis examining the cardiovascular outcomes of revascularization strategies compared to OMT. Research Question: Is revascularization associated with improved cardiovascular outcomes in patients with severe stable ICM compared to OMT alone? Methods: PubMed, Embase, Cochrane, CT.gov, ICTRP were searched using the search terms “coronary artery bypass grafting (CABG)” or “percutaneous coronary intervention (PCI)” versus “OMT” and “ICM” or “heart failure (HF)” from inception till May 2023. Included studies compared all-cause mortality, cardiovascular mortality, HF-related deaths, acute myocardial infarction (AMI), stroke and HF hospitalization. Data were pooled into risk ratios (RR) using fixed-effects model. Results: 3 studies (n= 2050, Revascularization = 1026 and OMT= 1024) met our inclusion criteria. The follow-up period ranged from 3.4-9.8 years. Revascularization strategies primarily through CABG had protective effects for all-cause mortality (RR 0.91, 95% CI 0.84-0.98, p= 0.01, I2 0%, N= 3 studies), cardiovascular death (RR 0.83, 95% CI 0.74-0.93, p=0.00, I2 0%, N= 2 studies) and HF hospitalizations (RR 0.80, 95% CI 0.69-0.93, p= 0.00, I2 19.20%, N= 2 studies). No significant differences were observed in risks of HF related deaths, AMI and stroke between the two strategies. Conclusions: Revascularization primarily through CABG reduces all-cause and cardiovascular mortality as well as HF hospitalizations in severe stable ICM. Further studies are warranted to determine which patients can derive the greatest advantages from revascularization.

Clinical manifestations of damage to the cardiovascular system and predictors of poor prognosis of Takayasu arteritis in Kyrgyz patients

Damage to the cardiovascular system (CVS) in Takayasu arteritis (AT) is characterized by a wide range of clinical manifestations and an unfavorable prognosis of the disease. Objectives: determine the characteristics of clinical manifestations of damage to the CVS and predictors of unfavorable prognosis in Kyrgyz patients with АТ. Methods: The study included 135 patients with a reliable diagnosis of AT, verified according to the classification criteria of the American College of Rheumatology/The European Alliance of Rheumatology Associations (ACR/EULAR, American College of Rheumatology/European Alliance of Associations for Rheumatology). All patients underwent clinical and standard laboratory and instrumental examination. Results: CVC lesion was observed in 84.4% of patients with AT and was manifested mainly by secondary arterial hypertension (AH) and aortic regurgitation (AR) – 52.8% and 27.8% of cases, respectively. The main cause of secondary hypertension was renovascular hypertension (63.4%). Myocarditis (8.5%) and coronary syndrome (3.8%) were significantly less frequently diagnosed. Among the cardiovascular complications (CVc) that developed in 32.5% of patients, decompensated chronic heart failure (DCHF) (48.7%) and acute cerebrovascular accident (ACVA) were the most common (40,5%). The immediate cause of death in the observed cohort was DCHF (66.7%) due to severe AR (83.3%) and ischemic cardiomyopathy (16.7%). Predictors of the development of CVc were the V anatomical type of vascular lesion, high activity of the pathological process, severity of stenotic changes, serious clinical complications (CC) and severe AR (p&lt;0.05). Conclusion: 1. CVS lesion was observed in 84.4% of Kyrgyz patients with AT. 2. The most frequent variant of cardiovascular pathology was secondary hypertension (52.8%) caused by vasorenal (63.4%), coarctation (33%) and aortic (3.6%) changes. The second most common was pathology of the aortic valve (27.8%) with a predominance of minor AR (45.8%). 3. CVc was observed in one third of patients (32.5%) and in most cases were presented with DCHF (48.7%) and ACVA (40.5%). 4. Unfavorable factors associated with an increased risk of CVc in the observed patients were V anatomical type of vascular lesion, high activity, pronounced stenotic changes, severe CC and severe AR (p&lt;0.05).

Long-Term Outcomes Among Patients With Severe Ischaemic Cardiomyopathy Undergoing Revascularisation by Coronary Artery Bypass Grafting or Percutaneous Coronary Intervention

Long-Term Outcomes Among Patients With Severe Ischaemic Cardiomyopathy Undergoing Revascularisation by Coronary Artery Bypass Grafting or Percutaneous Coronary Intervention

Revascularization in Ischemic Heart Failure with Reduced Left Ventricular Ejection Fraction

Coronary artery disease (CAD) is estimated to account for over 60% of heart failure (HF) patients and is associated with worse outcomes than a non-ischemic etiology. In patients with ischemic HF, myocardial revascularization has multiple mechanisms of action based on the concept that blood flow restoration of viable but underperfused myocardium might reverse the hibernation of the left ventricle and prevent future spontaneous myocardial infarction, which could potentially improve patients' outcomes. Here, we aim to elaborate on indications, timing, type, and impact of completeness of revascularization in patients with heart failure with reduced ejection fraction (HFrEF) and ischemic etiology. For decades, coronary artery bypass graft surgery has been the pilar of revascularization in patents with multivessel CAD and reduced EF. Recent development in the interventional field led to overall increase of percutaneous coronary intervention (PCI) adoption in treatment of ischemic HFrEF. However, recently published randomized study demonstrated no added benefit of PCI over optimal medical therapy in patients with severe ischemic cardiomyopathy challenging the beneficial role of revascularization in this setting. Since the decision on revascularization in ischemic cardiomyopathy frequently cannot be made based strictly on guidelines, tailored treatment strategy should be mandated with the essential role of multidisciplinary approach. These decisions should be based on capability to achieve complete revascularization, with the consideration that in certain situations it may not be accomplished.

The impact of viability assessment using cardiac MRI and echocardiogram on the outcome of revascularization in patients with multi-vessels coronary artery disease and moderate to severe ischemic cardiomyopathy.

To investigate the influence of viability assessment in the management of patients with ischemic cardiomyopathy (ICM). This retrospective cohort study included all patients with ICM with moderate to severely reduced left ventricular ejection fraction (LVEF) who underwent viability assessment using cardiac magnetic resonance imaging (MRI) and echocardiogram as modalities of imaging. In addition, LVEF, modality of choice, and treatment plans were all extracted as main variables from the electronic database. One hundred 6 patients who met the inclusion criteria from December 2014 to December 2019 were included. Posttreatment LVEF improved by 5% in the viable group compared to the nonviable group (p=0.016). Regardless of the treatment received, 6 (8.8%) patients in the viable group died due to cardiac causes after an 18-month follow-up period; in contrast, 7 (18.4%) patients died due to cardiac causes in the nonviable group. However, despite that difference, this was not statistically significant (p=0.153). Medical therapy alone was observed in 32 (84.2%) patients in the nonviable group compared to 32 (47.1%) in the viable group (p<0.001). Although the reduction in hospitalization for cardiac reasons was not statistically significant, the viable arm had 50% fewer hospitalizations than the nonviable arm (p=0.051). Patients with viable myocardium had better outcomes in which LVEF significantly improved posttreatment. Additionally, there was a reduction in the number of hospitalizations for cardiac reasons in the viable group compared to the nonviable group, even though the difference was not statistically significant. However, further studies with a larger number of patients are needed to determine a definite conclusion.

Examination of whole lengths of coronary arteries by color flow echocardiography

Introduction: increased cases of cardiac diseases in our world, and the absence of non-invasive, accurate, and feasible method of examination necessitate the looking for one's which achieved these criteria, that is the visualization of the coronary arteries (CAs) by means of the color flow transthoracic echocardiography. Aim of work: To check the possibilities of color flow mode of Transthoracic Echocardiography for seeing the whole lengths of coronary arteries and areas of stenosis, dilatations, and possibilities of visualization of collateral vessels. Materials and Methods: In Adhale governorate, Yemen republic, an observational study was conducted at Dr. Nashwan Al-Ashwal Clinic for medical and cardiac diseases. Cases were selected randomly. The total number of them was 763 participants, 700 males and 63 female ranging from 5 months to 70 years old, and then divided into two groups; 228 control and 535 patients. Period of study was from 1st January to 31th December 2021. The collected information was entered into Microsoft excel and word. Technique of examination by using of routine transthoracic echocardiography and the color flow mode with adjustments of its parameters as explained in the context. Results: A success in visualization of the whole lengths of coronary arteries in all patients (100%), in addition to some other features also were seeing, as the following: "group 1" few areas of beaded shape scattered along the vessel course, and one or two blue segments connecting the red vessel end to end of the same artery, and small area/areas of either red or blue colors with network shapes, while in "group 2"; there are more beaded areas, more than two areas of mosaic color reflections (stenosis), arterial segment/segments with dilatation, more than two blue segments of short or long distances that connecting end to end of the same red (artery) vessel and to another vessel/vessels, local and diffused color changes in the blue (collateral arteries or connector vessel) or red vessels to tint white or yellow colors respectively, large areas of either red or blue color (network arteries), blood pooling focus that pumping blood into more than one areas distal to level/levels of coronary arteries stenosis, and lastly, appearance of a darken area/side in the left ventricle. decreased in /absence of blood vessels, particularly, the red ones, in few patients with severe ischemic dilated cardiomyopathy. Conclusion: The examinations by color flow mode of transthoracic echocardiography permits the visualization of whole lengths of coronary arteries, stenotic and dilated segments, in addition to the small coronary arteries and the collateral vessels or rescuing circulation, and discovered that the collateral circulation is in needs for higher pressure in the pre stenotic segments, to open their vessels one by one, and also to facilitate blood flowing through the stenotic segments before development of collateral circulations, that also affected by atherosclerotic changes, and leads to arise of blood pooling focus.

Autologous CD133 + Cells and Laser Revascularization in patients with severe Ischemic Cardiomyopathy.

We tested the hypothesis that targeted TMLR combined with intramyocardial injection of autologous CD 133+ progenitor cells is safe and feasible in patients with chronic ischemic cardiomyopathy (ICM) and no revascularization options. Eight male patients (age 62 ± 2.4years) with multivessel severe ischemic heart disease and no revascularization options were enrolled. Autologous CD 133 + endothelial progenitor cells were derived and purified from the bone marrow on the day of surgery using the clinical-grade closed CliniMACS system. Using a lateral thoracotomy approach, TMLR was performed, followed by transmyocardial transplantation of purified CD133 + cells (mean number of transplanted cells: 12.5 × 106) in the region surrounding the TMLR sites. These sites were selected based on ischemia on pre-procedure perfusion imaging. We performed clinical and myocardial perfusion imaging pre-procedure and then at 6- and 12-month follow-up. No major complications or death occurred during the procedure or during the peri-operative hospital stay. One patient died of cardiac cause 6months post-procedure. There was a reported short-term improvement in anginal and heart failure symptoms and a modest reduction in the ischemic score as assessed by perfusion imaging. Our phase 1 clinical study examining the combination therapy of targeted transmyocardial laser revascularization therapy and autologous CD133 + endothelial progenitor cells in patients with chronic ICM and no revascularization options demonstrates the feasibility and short-term safety of this combined approach and warrants future larger phase 2 randomized clinical studies.

Electrical Storm in the ICU – When all Options Run Out

The management of patients with ischaemic cardiomyopathy presenting with refractory ventricular arrhythmias may be challenging and is associated with high morbidity and mortality. The authors present the case of a 72-year-old male patient with a known history of severe ischemic cardiomyopathy and impaired left ventricular function (LVEF 29%) with a previous episode of incessant ventricular tachycardia (VT), previously submitted to VT catheter ablation and implantable cardioverter-defibrillator (ICD) implantation in secondary prevention. Due to hyperthyroidism with amiodarone, he was under dofetilide therapy. In this case report, we detail the step-by-step approach undertaken in the management of a complex case of refractory electrical storm. The therapeutic approach included the use of several anti-arrhythmic drugs (amiodarone, lidocaine and esmolol), manual ICD anti-tachycardia pacing and cardioversion, sedation and mechanical ventilation, extracorporeal life support with VA-ECMO and VT catheter ablation under VA-ECMO support. Unfortunately, despite every measure undertaken, the patient developed incessant VT culminating in haemodynamic collapse and death. The role of mechanical circulatory support in haemodynamically unstable patients with refractory ventricular arrhythmias and undergoing VT catheter ablation is also explored, as well as other treatment options that may be considered in the management of electrical storm, such as early coronary angiography, autonomic modulation, and surgical VT ablation with electroanatomical mapping.

The REVIVED-BCIS2 trial: percutaneous coronary intervention vs. optimal medical therapy for stable patients with severe ischaemic cardiomyopathy.

The REVIVED-BCIS2 trial: percutaneous coronary intervention vs. optimal medical therapy for stable patients with severe ischaemic cardiomyopathy.

Recurrence of LV Thrombus in a Patient with Severe Ischaemic Cardiomyopathy Anticoagulated with Apixaban

Background Anticoagulation with warfarin remains the mainstay treatment for left ventricular thrombi. Although successful thrombus resolution has been reported with direct oral anticoagulants' (DOACs') recurrence/progression while resuming Apixaban therapy is yet to be reported. Case Presentation. This case report describes left ventricular thrombus progression/recurrence in a patient anticoagulated with Apixaban undergoing implantable cardioverter defibrillator to cardiac resynchronisation therapy with defibrillator upgrade procedure. He was thereafter changed to warfarin. Contrast echocardiogram at 6 months follow-up did not identify the previously demonstrated mural thrombus. Conclusion Prospective randomised control trials should be conducted in patients with left ventricular thrombus to compare anticoagulants, assess the efficacy and safety of DOACs, and evaluate uninterrupted DOAC versus transient withdrawal for cardiac device procedures.

The Beneficial Effects of Coronary Artery Bypass Grafting among Patients with Severe Ischemic Cardiomyopathy (Ejection Fraction ≤25%)

The Beneficial Effects of Coronary Artery Bypass Grafting among Patients with Severe Ischemic Cardiomyopathy (Ejection Fraction ≤25%)

Above knee amputation in a geriatric patient with severe ICMP and DM2: A case report

Geriatric patients with cardiac dysfunction are always a nightmare for anaesthetist in terms of successful intraoperative and postoperative management. We are presenting a case of 68-year-old male patient admitted in surgical emergency with rapidly progressive wet gangrene of right leg. He was a diagnosed case of severe Ischemic cardiomyopathy (ICMP) and Diabetes mellitus type 2 (DM-2) since last 10 years on medications. However, he was non-compliant with medications and had developed severe limitation in the functional status with metabolic equivalents &amp;#60;4 (METs&amp;#60;4) and complaints of chest pain even on minimal exertion. In view of the rapidly progressive wet gangrene and risk of sepsis leading to high possibility of morbidity and mortality, an urgent above knee amputation was planned. However due to the risks associated with general anaesthesia and central neuraxial blockade, an safe anesthesia plan was formulated and implemented utilising only the lower limb blocks to achieve a safe conduct of anaesthesia.

Coronary Artery Reimplantation and Berlin Heart EXCOR Rescue for Left Coronary Artery Atresia With Severe Ischemic Cardiomyopathy.

We describe a successful bridge to recovery by coronary reimplantation and Berlin Heart EXCOR left ventricular assist device in a child with left main coronary artery ostial atresia and severe ischemic cardiomyopathy.