Venovenous Bypass Research Articles

P-938. Percutaneous Mechanical Aspiration in Drug Use Associated-Infective Endocarditis

Abstract Background Intravenous drug use is a known risk factor for infective endocarditis (IE). Incidence of drug use associated-infective endocarditis (DUA-IE) has increased in the US during the opioid epidemic. Management of DUA-IE, especially in patients deemed high surgical risk, is an area of need. Angiovac (AngioDynamics, Latham, NY) is a percutaneous mechanical aspiration device used for high-risk surgical patients to debulk right-sided intravascular material, including in IE, using a venous drainage cannula and extracorporeal veno-venous bypass. We review characteristics and outcomes of Angiovac for DUA-IE Methods Descriptive analysis of Angiovac cases performed between 2019-2023 at a large academic medical center in northern Manhattan. Cases were included if there were concurrent diagnoses of IE and intravenous drug use Results Ten cases were identified; all involved the native tricuspid valve. Overall, median age was 40 years, 70% (n=7) were female, 60% white and 80% Hepatitis C infected. Median duration of bacteremia was 7 days; 9 (90%) patients had Staphylococcus aureus. Seven patients had severe tricuspid regurgitation and 7 had at least one metastatic complication, most commonly vertebral osteomyelitis (4, 57%). Five patients remained bacteremic at time of Angiovac. Post-procedure cultures cleared in 1-7 days (median 3 days). Median duration of antibiotics was 42 days including use of intravenous (including dalbavancin) or oral. Most patients received medications for opioid use disorder while hospitalized. 40% (n=4) were readmitted by 90 days and two re-hospitalized patients had bacteremia; one of these cases was polymicrobial including the previous organism (methicillin-susceptible staphylococcus aureus). Nine patients were alive one-year post-procedure. The patient with polymicrobial bacteremia died after cardiac arrest in the context of suspected ongoing drug use Conclusion Angiovac led to blood culture clearance and 90% one-year survival in a small cohort of patients with DUA-IE. Multidisciplinary approaches for care of these patients are critical and this minimally invasive procedure can be an important part of management. Future studies are needed to identify patients who would benefit from Angiovac and define optimal course of antibiotics post-procedure Disclosures Kartik Kodali, n/a, AbbVie: Stocks/Bonds (Public Company) Sanjum Sethi, MD, AngioDynamics: Advisor/Consultant|Chiesi: Honoraria|Inari: Advisor/Consultant|Janssen: Advisor/Consultant|Penumbra: Advisor/Consultant Sahil A. Parikh, MD, Abbott: Advisor/Consultant|Abbott: Grant/Research Support|Advanced Nanotherapies: Ownership Interest|Boston Scientific: Advisor/Consultant|Boston Scientific: Grant/Research Support|Cordis: Advisor/Consultant|Encompass Vascular: Ownership Interest|Inari: Advisor/Consultant|Medtronic: Advisor/Consultant|Penumbra: Advisor/Consultant|Penumbra: Grant/Research Support|Philips: Advisor/Consultant|Reflow Medical: Grant/Research Support|Shockwave Medical: Advisor/Consultant|Shockwave Medical: Grant/Research Support|Surmodics: Grant/Research Support|Terumo: Advisor/Consultant|TriReme Medical: Grant/Research Support|Veryan Medical: Grant/Research Support

Outcomes of Suction Debulking and Surgery in Patients With Isolated Tricuspid Valve Endocarditis.

Percutaneous vegetation debulking has been reported to treat tricuspid valve infective endocarditis (TVIE), but data on feasibility compared with conventional surgical strategies are limited. We aimed to compare short-term outcomes of suction debulking with partial venovenous bypass to conventional open surgery in this population. This was a single-center, retrospective study that included all patients with isolated TVIE who underwent suction debulking with partial venovenous bypass or tricuspid valve surgery between January 2010 and December 2022. Patient characteristics, procedural data, and clinical outcomes were compared. Of the 45 patients included, 16 (35.6%) underwent suction debulking and the remainder (64.4%) underwent surgery. Baseline characteristics were comparable, including high rates of preprocedure hemodialysis (11.1%), prior infectious endocarditis (44.4%), intravenous drug use (60.0%), presence of tricuspid bioprostheses (24.4%), and septic shock (40.0%). Suction debulking had a shorter procedure time than surgery (206 [176 to 224] min vs 400 [325 to 487] min, P < 0.001) and was associated with numerically lower rates of various complications including acute kidney injury requiring hemodialysis, limb ischemia, and dysrhythmia requiring pacemaker. Over a mean follow-up period of 473 ± 604 days, recurrent endocarditis (37.5% vs 17.2%, P = 0.25) and the need for reintervention (50.0% vs 17.2%, P = 0.048) were higher with suction debulking. However, all-cause mortality was similar between the groups (12.5% vs 10.3%, P > 0.99). Suction debulking can safely be performed in patients with isolated TVIE with shorter procedural times and similar midterm all-cause mortality compared with surgery. Suction debulking may be appropriate initial therapy for this complex population.

Fine-Needle Portosystemic Pressure Gradient as a Reference for Portal Hypertension in Patients with Intrahepatic Venovenous Shunt: A Prospective Study.

To evaluate the consistency and agreement between portal venous pressure measured by fine-needle (F), portal vein catheterization (D), and hepatic vein balloon-occlusion (W) in decompensated cirrhotic patients with intrahepatic venovenous shunts (IHVS). 156 consecutive patients planning to receive transjugular intrahepatic portosystemic shunt in our center were screened for study participation. The F/D/W were assessed for consistency by Pearson coefficient (r), linear regression coefficient (R2), and intraclass correlation coefficient (ICC), and for disagreement (error exceeding 20% of D) by Bland-Altman method. Of 92 eligible patients, F was successfully obtained in 37 (40.2%) with IHVS, with no puncture-related complications. In these patients, there were significant differences between W/D (-14.3 mmHg, p<0.001) with poor consistency (r=0.410, R2=0.168, ICC=0.105), but only minor differences between F/D (-0.5 mmHg, p=0.134) with good consistency (r=0.951, R2=0.904, ICC=0.944). This pattern did not alter when their pressure gradients were compared (R2=0.083/0.767) and adjusted by stiffness measurements and platelet counts (R2=0.196/0.789). The W/D and F/D disagreement occurred in 47.8% (34 with IHVS, 91.9%) and 0.0% of patients, respectively. In multivariate linear regression, only the presence of portal vein thrombosis (p=0.045) was an independent predictor for the lower F/D ratio. Portosystemic pressure gradient of F showed greater ability to stratify that of D of 16 (AUC: 1.000 vs. 0.574, p<0.001) and 20 (0.974 vs.0.662, p=0.001) mmHg than that of W. Fine-needle portal venous pressure measurement could be a valid and safe approach to reflect the severity of sinusoidal portal hypertension in patients with IHVS.

Risk factors for intrahepatic venovenous shunt in patients with cirrhosis and its impact on hepatic venous pressure gradient

Objective: To evaluate the factors affecting the incidence of intrahepatic venovenous shunt (IVVS) in patients with cirrhosis and its impact on hepatic venous pressure gradient (HVPG). Methods: A retrospective analysis was performed on the data of patients with liver cirrhosis who received HVPG measurement in Nanjing Drum Tower Hospital from April 2013 to March 2022. Univariate and multivariate regression analyses were used to investigate the incidence rate and risk factors of IVVS and its impact on HVPG. The t-test and rank-sum test were used for the measurement data, and the χ2 test was used for the count data. Results: A total of 242 cases with cirrhosis were included in the statistical analysis, including 54 (22.3%) with IVVS and 188 (77.7%) without IVVS. There was a statistically significant difference (P<0.05) in prothrombin time (PT), HVPG, and splenectomy history between the two groups of patients' baseline data (all P<0.05). The multiple logistic regression analysis results showed that PT was an independent risk factor for the occurrence of IVVS (P<0.05), and patients combined with IVVS had lower HVPG values [(17.58±5.57) mmHg vs. (11.92±5.38) mmHg, 1 mmHg=0.133 kPa; t=6.623, P<0.001]. Conclusions: Patients with liver cirrhosis have a high incidence rate of IVVS, which is closely associated with a low prothrombin time. Additionally, patients combined with IVVS have low HVPG values, which affect its accuracy.

Donation After Circulatory Death Liver Transplantation: Impact of Normothermic Machine Perfusion on Key Variables.

During orthotopic liver transplantation, allograft reperfusion is a dynamic point in the operation and often requires vasoactive medications and blood transfusions. Normothermic machine perfusion (NMP) of liver allografts has emerged to increase the number of transplantable organs and may have utility during donation after circulatory death (DCD) liver transplantation in reducing transfusion burden and vasoactive medication requirements. This is a single-center retrospective study involving 226 DCD liver transplant recipients who received an allograft transported with NMP (DCD-NMP group) or with static cold storage (DCD-SCS group). Veno-venous bypass was not used in any patients. Infusion doses of norepinephrine, epinephrine, and vasopressin as well as bolus doses of vasoactive medications during reperfusion were recorded. Blood component therapy was recorded according to phase of liver transplantation and during the first 24 hours postprocedure. A total of 103 recipients in the DCD-NMP group and 123 patients in the DCD-SCS group were included. Post-reperfusion syndrome (PRS) incidence was reduced in the DCD-NMP group compared to the DCD-SCS group (10.7% [95% confidence interval, CI, 5.5%-18.3%] vs 42.3% [95% CI, 33.4%-51.5%]; P < .001). During the reperfusion period, patients in the DCD-SCS group required increased bolus doses of epinephrine and vasopressin compared to the DCD-NMP group (24.6 vs 7.5 µg; P < .001) and (5.4 vs 2.4 units; P < .001), respectively. The DCD-SCS group received a higher infusion dose of epinephrine during anhepatic phase, at reperfusion, and up to 90 minutes after reperfusion. In the postreperfusion period, there were significant increases in the transfusion of red blood cells (RBCs; 5.3 vs 3.7 units; P = .006), fresh frozen plasma (FFP; 3.4 vs 1.9 units; P < .001), cryoprecipitate (2.7 vs 1.8 pooled units; P = .015) and platelets (0.9 vs 0.4 units; P = .008) in the DCD-SCS group compared to the DCD-NMP group. During the first 24 hours postprocedure, transfusion of RBCs, FFP, and cryoprecipitate in the DCD-SCS group was increased compared to the DCD-NMP group ([2.6 vs 1.7 units; P = .028], [1.6 vs 0.8 units; P < .001], [1.5 vs 0.9 pooled units; P = .031]) respectively. Administration of tranexamic acid was more frequent in the DCD-SCS group during the post-reperfusion period compared to the DCD-NMP group (13% [95% CI, 5.7%-17.4%] vs 3.9% [95% CI, 1.1%-9.6% 95%]; P = .018). In DCD liver transplantation, use of NMP was associated with reduced incidence of PRS and decreased vasopressor and inotrope requirements at the time of allograft reperfusion compared to using SCS. Additionally, NMP was associated with reduced transfusion of all blood product components as well as antifibrinolytic agent administration in the post-reperfusion period. Reduced transfusion burden in the DCD-NMP group also occurred during the first 24 hours posttransplant.

The Balloon Catheter Method and the End-hole Catheter Method in the Measurement of Hepatic Venous Pressure Gradient: a Comparative Study.

This study aims to evaluate the differences between The balloon catheter method and End-hole Catheter Method in measuring hepatic venous pressure gradient (HVPG) among cirrhosis patients. From October 2017 to January 2024, patients who underwent HVPG measurements using both methods were consecutively included. HVPGs obtained from both methods were compared with the portal vein pressure gradient (PPG) obtained via transjugular intrahepatic portosystemic shunt (TIPS) using paired comparisons. Additionally, the consistency and predictive ability for bleeding risk of the two methods, as well as the impact of intrahepatic veno-venous shunt (IHVS), were analyzed. The study enrolled 145 patients, each of whom had HVPG measured by both methods. PPG was measured in 61 patients. There was a statistically significant difference between the PPGs and HVPGs measured by both the balloon catheter method and the end-hole catheter method (P < 0.001), with the HVPG mean values obtained by the end-hole catheter method being closer to the PPGs. In the non-IHVS group, no significant statistical difference was found between the two methods (P = 0.071). In contrast, the IHVS group showed a significant difference (P < 0.001), with a mean difference of 2.98 ± 4.03mmHg. When IHVS was absent, the measurement results from the end-hole catheter method and the balloon catheter method were found to be highly correlated. The end-hole catheter method has a higher screening capability for patients at risk of bleeding compared to the balloon catheter method (75.90% vs. 72.86%). HVPG measurements using either the balloon catheter method or end-hole catheter method showed significant difference with the PPG. The end-hole catheter method has a higher screening capability for patients at risk of bleeding, and IHVS could lead to lower HVPG measurements with The balloon catheter method.

Ante Situm Liver Resection for Tumors Invading the Inferior Vena Cava Hepatic Vein Confluence.

Liver malignancy invading the retrohepatic inferior vena cava beyond the cavo-hepatic vein venous confluence can be resected by an ante situm technique first described by Hannoun et al.1 In this approach, a major hepatectomy is performed and the hepatic veins are sectioned to allow the inferior vena cava reconstruction while the liver is cold perfused and the liver remains within the abdominal cavity. The hepatic vein is then reimplanted on the reconstructed inferior vena cava in "a liver autotransplantation fashion." The patient was a 66-year-old with a recurrent adrenocortical carcinoma cancer invading the right liver and the retrohepatic inferior vena cava with intraluminal thrombus extending beyond to the hepatic vein confluence. A right hepatectomy extended to segment 1 and the retrohepatic inferior vena cava was planned because of the intracaval tumoral thrombus and the infiltration of the right liver. The future liver remnant (FLR) (646 cc) to total liver volume (1526 cc) ratios was 42% while the FLR to patient weight ratio was 0.9%. The parenchymal liver transection was performed under a total vascular exclusion, venovenous bypass, and hypothermic perfusion of the left liver.2 The common trunk of the left and middle hepatic veins was sectioned, allowing the liver to be rotated toward the left. Vena cava reconstruction was achieved by a ringed Gore-Tex prosthesis, with reimplantation of the left and middle hepatic veins directly over the prosthesis. Surgery lasted 580 min, total duration of venovenous bypass and liver vascular exclusion was 143 min and 140 min, respectively. Blood loss was 2 liters and 8 red blood cell (RBC) units were transfused. The patient spent 5 days in the ICU, liver function tests normalized by postoperative day 8 and patient was discharged home on postoperative day 20; 1 year later, the patient is alive and disease free under mitotane treatment. The ante situm technique represents a safe surgical option for complex liver resection for malignancy involving the cavo-hepatic venous confluence. Compared with the ex situ liver resection, this technique allows liver remnant outflow reconstruction to be performed while the liver is cold perfused within the abdominal cavity with an intact hepatic pedicle.

Cross-circulation combined with rapidly deployable veno-venous bypass grafts for multi-organ biosystemic support in liver failure: Experimental studies.

Liver failure remains a critical clinical challenge with limited treatment options. Cross-circulation, the establishment of vascular connections between individuals, has historically been explored as a potential supportive therapy but with limited success. This study investigated the feasibility of combining cross-circulation with a rapidly deployable veno-venous bypass (VVB) graft for multi-organ support in a rat model of total hepatectomy, representing the most severe form of liver failure. A Y-shaped VVB graft was fabricated using coaxial electrospinning of PLCL/heparin nanofibers and magnetic rings for rapid anastomosis. After total hepatectomy in rats, the VVB graft was implanted to divert blood flow. Cross-circulation was then established between anhepatic and normal host rats. Hemodynamics, biochemical parameters, blood gases, and survival were analyzed across three groups: hepatectomy with blocked vessels (block group), hepatectomy with VVB only (VVB group), and hepatectomy with VVB and cross-circulation (VVB/cross-circulation group). The VVB graft exhibited suitable mechanical properties and hemocompatibility. VVB rapidly restored hemodynamic stability and mitigated abdominal congestion post-hepatectomy. Cross-circulation further ameliorated liver dysfunction, metabolic derangements, and coagulation disorders in anhepatic rats, significantly prolonging survival compared to the VVB group (mean 6.56±0.58 vs 4.05±0.51h, P<0.05) and the block group (mean 1.01±0.05h, P<0.05). Combining cross-circulation with a rapidly deployed VVB graft provided effective multi-organ biosystemic support in a rat model of total hepatectomy, substantially improving the biochemical status and survival time. This approach holds promise for novel liver failure therapies and could facilitate liver transplantation procedures.

Harmonizing Definitions and Perspectives in Extreme Liver Surgery

Objective: To propose to our community a common language about extreme liver surgery. Background: The lack of a clear definition of extreme liver surgery prevents convincing comparisons of results among centers. Methods: We used a two-round Delphi methodology to quantify consensus among liver surgery experts. For inclusion in the final recommendations, we established a consensus when the positive responses (agree and totally agree) exceeded 70%. The study steering group summarized and reported the recommendations. In general, a five-point Likert scale with a neutral central value was used, and in a few cases multiple choices. Results are displayed as numbers and percentages. Results: A two-round Delphi study was completed by 38 expert surgeons in complex hepatobiliary surgery. The surgeon´s median age was 58 years old (52-63) and the median years of experience was 25 years (20-31). For the proposed definitions of total vascular occlusion, hepatic flow occlusion and inferior vein occlusion, the degree of agreement was 97%, 81% and 84%, respectively. In situ approach (64%) was the preferred, followed by ante situ (22%) and ex situ (14%). Autologous or cadaveric graft for hepatic artery or hepatic vein repair were the most recommended (89%). The use of veno-venous bypass or portocaval shunt revealed the divergence depending on the case. Overall, 75% of the experts agreed with the proposed definition for extreme liver surgery. Conclusion: Obtaining a consensus on the definition of extreme liver surgery is essential to guarantee the correct management of patients with highly complex hepatobiliary oncological disease. The management of candidates for extreme liver surgery involves comprehensive care ranging from adequate patient selection to the appropriate surgical strategy.

Venovenous bypass in liver transplantation: Exploring the benefits, efficacy, and safety.

Venovenous bypass (VVB) is a technique used in liver transplantation (LT) to maintain hemodynamic stability and abdominal organ perfusion and thereby improve patient outcomes. Despite its perceived benefits, VVB utilization has declined globally due to concerns related to heparinization, major bleeding and the need for expertise. Recent advancements, such as percutaneous cannulation techniques and improved extracorporeal technology have improved the safety of VVB in LT. This paper presents a modified VVB circuit with enhanced safety features. Cannulation plays a pivotal role in VVB establishment, with percutaneous methods increasingly favored. Studies demonstrate VVB's efficacy in improving patient outcomes with lower incidence of acute kidney injury and reduced operative time and blood loss, with no added morbidity or mortality. However, its routine use faces challenges, with alternative techniques gaining traction. Our experience highlights VVB's role in various clinical scenarios, including patients with high Model for End-Stage Liver Disease (MELD) scores, challenging surgical anatomy, portal vein thrombosis and pre-existing cardiovascular disease, emphasizing its safety and efficacy. Continued research is needed to optimize VVB techniques and ensure better outcomes for liver transplant recipients.

Complex Hepatectomy Under Total Vascular Exclusion of the Liver Preserving the Caval Flow with Portal Hypothermic Perfusion and Temporary Portacaval Shunt: A Proof of Concept.

Hypothermic liver perfusion decreases ischemia/reperfusion injury during hepatectomy under standard total vascular exclusion (TVE) of the liver. This surgery needs venovenous bypass and is hampered by high morbi-mortality. TVE preserving the inferior vena cava (IVC) flow is hemodynamically well tolerated but remains limited in duration when performed under liver normothermia. The objective of this study was to report the results of TVE preserving the caval flow, modified to allow hypothermic liver perfusion and obviate splanchnic congestion. The technique, indicated for tumors abutting large tributaries of the hepatic veins but sparing their roots in IVC and the latter, was applied when TVE was anticipated to last for ≥ 60 min. It combines continuous TVE preserving the IVC flow with hypothermic liver perfusion and temporary portacaval shunt (PCS). Results are given as median (range). Vascular control was achieved in 13 patients with excellent hemodynamical tolerance. PCS was direct or via an interposed synthetic graft (five and eight cases, respectively). Liver temperature dropped to 16.5 (6-24) °C under perfusion of 2 (2-4) L of cold perfusate. TVE lasted 67 (54-125) min and 4.5 (0-8) blood units were transfused. Resection was major in nine cases and was complete in all cases. Five complications occurred in four patients, and the 90-day mortality rate was zero. This technique maintains stable hemodynamics and combines the advantages of in situ or ex situ standard TVE with hypothermic liver perfusion, without their inherent prolongation of ischemia time and need for venovenous bypass.

The effects of venovenous bypass use in liver transplantation with piggyback technique: a propensity score-weighted analysis.

Venovenous bypass (VVB) use during liver transplantation (LT) is notably variable among the centres and it is actually restricted to surgically complex cases, severely unstable recipients or grafts from high-risk donors. Historically, VVB was associated with the classical LT with caval cross clamping, while not much is known about the safety of this technique applied to piggyback LT. This retrospective observational study evaluated the effects of VVB applied to piggyback LT on mortality, hospital outcomes, postoperative graft and other organ dysfunction. We retrospectively collected data about recipient status, surgical complexity and graft quality of all the piggyback LTs performed at the Transplant Unit of IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy, from January 2012 to December 2022. A propensity score (PS) was built taking into account the variables possibly associated with either VVB choice and the investigated outcomes with the average treatment overlap method. PS-weighted general linear models (GLMs) were developed to investigate the adjusted effect of VVB use on the selected outcomes. The final analysis included 874 LT cases, of whom 74 (8.5%) underwent VVB. The effective sample sizes after PS-weighting were 280.2 and 64.3 patients in the no-VVB and VVB groups, respectively. PS-weighted GLMs did not show any differences regarding hospital and graft-related outcomes. However, significantly higher odds ratios for serum creatinine > 2mg/dL and AKIN stage 2 or 3 during the first 24h after ICU admission together with a higher renal replacement therapy need during ICU stay were reported for VVB exposure in the weighted analyses. This study suggests similar mortality and length of stay but a higher risk for postoperative acute kidney injury in patients undergoing piggyback LT with VVB.

Liberal use of veno-arterial extracorporeal membrane oxygenation in combined sequential heart-liver transplantation.

Combined heart-liver transplantation (CHLT) is a rarely though increasingly performed procedure with evolving indications. Despite CHLT being performed at only a handful of centers, the use of intraoperative mechanical circulatory support to optimize hemodynamics and facilitate dual-organ transplantation varies widely. At our center, we liberally utilize veno-arterial extracorporeal membrane oxygenation (V-A ECMO) when a veno-venous shunt is anticipated to be insufficient in mitigating the hemodynamic perturbations associated with liver reperfusion. In this series, we describe our experience with V-A ECMO in sequential (heart-first) CHLT and demonstrate highly favorable outcomes with this strategy.

Venovenous bypass in adult liver transplant recipients: A single-center observational case series.

Very little information is currently available on the use and outcomes of venovenous bypass (VVB) in liver transplantation (LT) in adults in Australia. In this study, we explored the indications, intraoperative course, and postoperative outcomes of patients who underwent VVB in a high-volume LT unit. The study was a single-center, retrospective observational case series of adult patients who underwent VVB during LT at Austin Health in Melbourne, Australia between March 2008 and March 2022. Information on baseline preoperative status and intraoperative variables, including specific VVB characteristics as well as postoperative and VVB-related complications was collected. The lengths of intensive care unit and hospital stays as well as intraoperative and in-hospital mortality were recorded. Of the 900 LTs performed at this center during the aforementioned 14-year period, 27 (3%) included a VVB procedure. VVB was performed electively in 16 of these 27 patients (59.3%) and as a rescue technique to control massive bleeding in the other 11 (40.1%). The median (interquartile range [IQR]) age of those who underwent VVB procedures was 48 (39-55) years; the median age was 56 (47-62) years in the non-VVB group (p<0.0001). The median model for end-stage liver disease (MELD) scores were similar between the two patient groups. Complete blood data was available for 622 non-VVB patients. Twenty-six VVB (96.3%) and 603 non-VVB (96.9%) patients required intraoperative blood transfusions. The median (IQR) number of units of packed red blood cells transfused was 7 (4.8-12.5) units in the VVB group compared to 3.0 units (1.0-6.0) in the non-VVB group (p<0.0001). Inpatient mortality was 18.5% and 1.1% for the VVB and non-VVB groups, respectively (p<0.0001). There were no significant differences in length of hospital stay or incidence of acute kidney injury, primary graft dysfunction, or long-term graft failure between the two groups. Patients in the VVB group experienced a higher rate of postoperative non-anastomotic biliary stricture compared to patients in the non-VVB group (33% and 7.9%, respectively; p = 0.0003). VVB continues to play a vital role in LT. This case series highlights the heightened risk of major complications linked to VVB. However, the global transition to selective use of VVB underscores the urgent need for collaborative multi-center studies designed to address outstanding questions and parameters related to the safe implementation of this procedure.

Troponin Elevation in Patients Undergoing Percutaneous Hepatic Perfusion for Metastatic Uveal Melanoma.

Percutaneous Hepatic Perfusion (PHP) is a liver directed regional therapy recently FDA approved for metastatic uveal melanoma to the liver involving percutaneous isolation of liver, saturation of the entire liver with high-dose chemotherapy and filtration extracorporeally though in line filters and veno-venous bypass. The procedure is associated with hemodynamic shifts requiring hemodynamic support and blood product resuscitation due to coagulopathy. To assess the cardiac safety and subsequent clinically significant sequalae of this therapy. Consecutive PHP procedures done at our center between 2010-2022 were assessed retrospectively. Cardiac risk factors, post procedural cardiac enzymes, electrocardiograms, and transthoracic echocardiograms along with 90-day cardiac outcomes were reviewed. All data were reviewed by cardio-oncologists at our institution. Of 37 patients reviewed, mean age was 63years and 57% were women. 132 procedures were performed with an average of 3.57 procedures per patient. 68.6% of patients had elevated troponin during at least 1 procedure. No patients were found to have acute coronary syndrome, heart failure, unstable arrhythmias, or cardiac death. No patients had notable echocardiographic changes. 10.8% of patients with positive troponin had asymptomatic transient electrocardiographic changes not meeting criteria for myocardial infarction. One patient had non-sustained ventricular tachycardiac intra-operatively which did not recur subsequently. Three patients died from non-cardiac causes within 90-days. There was no oncology treatment interruption, even in those with troponin elevation. In multivariable analysis, a history of hyperlipidemia was a predictor of postoperative troponin elevation. (P = .042). Percutaneous Hepatic Perfusion is safe and associated with a transient, asymptomatic troponin elevation peri-operatively without major adverse cardiac events at 90days. The observed troponin elevation is likely secondary to coronary demand-supply mismatch related to procedural hemodynamic shifts, hypotension, and anemia.

Ante-situm central hepatectomy with ivc reconstruction under veno-venous bypass and liver hypothermic perfusion followed by auto-transplantation: an extreme complex liver surgery

Ante-situm central hepatectomy with ivc reconstruction under veno-venous bypass and liver hypothermic perfusion followed by auto-transplantation: an extreme complex liver surgery

Nuclear factor kappa-light-chain-enhancer of activated B cells gene expression involvement in porcine liver transplant experimental model.

Gene expressions of vascular Endothelial Growth Factor Alpha (VEGFa), Nuclear Factor Kappa-Light-Chain-Enhancer of Activated B cells (NFkB) and cytokines could be useful for identifying potential therapeutic targets to alleviate ischemia-reperfusion injury after liver transplantation. Cytokine gene expressions, VEGFa and NFkB were investigated in a preclinical swine model of liver transplantation. A total of 12 pigs were used as donors and recipients in liver transplantation without venovenous bypass or aortic clamping. NFkB, IL-6, IL-10, VEGFa and Notch1 gene expression were assessed. These samples were collected in two specific times: group 1 (n= 6) - control, samples were collected before recipient's total hepatectomy and group 2 - liver transplantation group (n=6), where the samples were collected one hour after graft reperfusion. Liver transplantation was successfully performed in all recipients. Liver enzymes were elevated in the transplantation group. NFkB gene expression was significantly decreased in the transplantation group in comparison with the control group (0.62±0.19 versus 0.39±0.08; p= 0.016). No difference was observed between groups Interleucine 6 (IL-6), interleucine 10 (IL-10), VEGFa and Notch homolog 1 (Notch1). In this survey a decreased NFkB gene expression in a porcine model of liver transplantation was observed.

A multipurpose Extracorporeal Life Support Circuit: a concept for multiorgan transplant and circulatory support service Healthcare provider

The demand for efficient and adaptable life support systems in the field of Extracorporeal Life Support (ECLS) is steadily increasing. To meet this growing need, there is a requirement for a versatile extracorporeal life support circuit that can be effectively applied in various medical scenarios, especially in tertiary hospitals where multiple ECLS services are utilized. These services include Extracorporeal Membrane Oxygenation (ECMO) for addressing respiratory or cardiac problems, Ventricular Assist Device (VAD) as a bridge to recovery or heart transplant, and Venovenous Bypass (VVB) for assisting liver transplantation. In light of this, we propose the creation of a multipurpose circuit that integrates multiple extracorporeal life support (ECLS) functions to cater to diverse medical needs. This innovative circuit not only offers cost-effectiveness and enhanced safety but also ensures optimal utilization, thereby revolutionizing the realm of life support technologies.

Use of the composite Y-shaped veno-venous bypass graft in coronary surgery

Introduction. This study was performed to assess the functional status of Y­shaped veno­venous bypass grafts in cases of lacking both arterial and venous material, as well as in patients with ascending aorta abnormalities, in order to perform the most adequate myocardial revascularisation. Material. The retrospective study performed in Scientific and Practical Center of Interventional Cardioangiology included 43 patients, who underwent surgery between 2017 and 2022. The main inclusion criterion for the study was coronary artery bypass grafting (CABG) with the use of Y­shaped venous conduits. The control bypass angiography was performed in average in 33 ± 8 months. All interventions were performed under normothermic cardiopulmonary bypass (CPB), and the average number of conduits per patient was 3.4. Results. Satisfactory functional status of the Y­shaped venous bypass grafts in the long­term (33 ± 8 months) period was observed in 86.1% of cases. At that, no cases of cerebrovascular accident were reported in the postoperative period, as well as no sternal infections in patients with insulin­dependent diabetes mellitus, and only one patient out of 20 patients with severe lower limb ischaemia had wound infection of the lower extremity (5%). Conclusions. Y­shaped veno­venous bypass grafts demonstrated quite acceptable long­term functional results in patients with ascending aorta abnormalities or conduit deficiency and they can be used to achieve the most adequate myocardial revascularisation. Keywords: CABG, Y­shaped bypass graft, venous conduit, aortic atheromatosis

ASO Author Reflections: Liver Resections with Vascular Reconstruction Using Veno-Venous Bypass and Cold Perfusion for Tumors with Venous Obstruction.

ASO Author Reflections: Liver Resections with Vascular Reconstruction Using Veno-Venous Bypass and Cold Perfusion for Tumors with Venous Obstruction.