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Heparin purge solution is recommended to be used in Impella devices to prevent biomaterial buildup and subsequent device dysfunction. The use of sodium bicarbonate purge solution in an Impella device is described in two patients with heparin-induced thrombocytopenia (HIT). The first case details a patient with severe mitral regurgitation and cardiogenic shock who had an Impella CP placed who developed HIT. Heparin purge solution was replaced by sodium bicarbonate purge solution in addition to systemic direct thrombin inhibitor (DTI) initiation. There was no significant change in Impella purge pressure or flow over the 13 days of Impella use. The second case describes a patient who developed an acute myocardial infarction and subsequent cardiogenic shock for which an Impella CP was placed who also developed HIT. Heparin purge solution was replaced by sodium bicarbonate purge solution. There was no significant change in purge pressure, flow, or motor current spikes over 11 days of use. In conclusion, we describe the successful use of a novel sodium bicarbonate purge solution utilized in patients with HIT for Impella management alone and in combination with systemic direct thrombin inhibitor therapy. This resulted in no protein deposition in the device gaps or device dysfunction. [ABSTRACT FROM AUTHOR]

We investigated patient outcomes in relation to their postoperative length of stay after minimally invasive valve surgery. All adults who survived elective, uncomplicated minimally invasive aortic or mitral valve surgery at a single center between 2012 and 2019 were classified by postoperative length of stay: early discharge (≤3 days) or late discharge (>3 days). The trend in early discharge was investigated over the study period, predictors of early discharge were identified using multivariate logistic regression modeling, and 1:1 propensity score matching was used to determine which patients in the late-discharge cohort had similar health to patients discharged early. Adjusted outcomes of 30-day mortality, readmission, and direct costs were analyzed. Among 1262 consecutive patients undergoing minimally invasive valve surgery, 618 were elective and uncomplicated, 25% (n = 162) of whom were discharged early. The proportion of early-discharge patients increased over time (P for trend <.05). A history of congestive heart failure, stroke, or smoking and higher Society of Thoracic Surgeons predictive risk of mortality score negatively predicted early discharge (P <.05). Propensity score matching identified 101 (22%) late-discharge patients comparable with early-discharge patients. Adjusted 30-day mortality and readmission rates were comparable between cohorts. The median direct costs per patient ($20,046 vs $22,124, P <.05) were significantly lower in the early-discharge cohort. In well-selected patients early discharge after minimally invasive valve surgery was associated with lower costs but comparable postoperative outcomes. About one-fifth of patients who remain in the hospital beyond postoperative day 3 may be candidates for earlier discharge. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive heart valve surgery has previously been shown to be safe and feasible in obese patients. Within this population, we investigated the effect of obesity class on the patient outcomes of minimally invasive aortic valve replacement (mini-AVR).Methods: A single-center retrospective cohort study of consecutive patients with obese body mass indices (BMIs) who underwent mini-AVR between 2012 and 2020. Patients were stratified into three groups according to Centers for Disease Control and Prevention adult obesity classifications: Class I (BMI: 30.0-<35.0), Class II (BMI: 35.0-<40.0), and Class III (BMI ≥ 40.0). The primary outcomes were postoperative length of stay (LOS), 30-day mortality, and direct cost.Results: Among 206 obese patients who underwent mini-AVR, LOS (Class I 5 [3-7] vs. Class II 6 [5-7] vs. Class III 6 [5-7] days; p = .056), postoperative 30-day mortality (Class I 2.44% [n = 3] vs. Class II 4.44% [n = 2] vs. Class III 7.89% [n = 3]; p = .200), and costs (Class I $24,118 [$20,237-$29.591] vs. Class II $22,215 [$18,492-$28,975] vs. Class III $24,810 [$20,245-$32,942] USD; p = .683) did not differ between obesity class cohorts.Conclusions: Mini-AVR is safe and feasible to perform for obese patients regardless of their obesity class. Patients with obesity should be afforded the option of minimally invasive aortic valve surgery regardless of their obesity class. [ABSTRACT FROM AUTHOR]

Background: Octogenarians undergoing cardiac surgery have higher mortality than their younger counterparts.Objectives: To determine if various risk factors have the same effect on mortality in octogenarians as in younger patients.Methods: The National Inpatient Sample data set from 2004 to 2014 was queried to select patients aged 65 years and older who underwent either coronary artery bypass grafting (CABG), valvular heart surgery (VHS), or both (CABG + VHS) within 10 days of hospital admission. The patients were divided into two groups 65-79 years and 80 years and greater. Hospital mortality, patient demographics, comorbidities, and type of hospital admission was evaluated and compared using χ2 and multivariable logistic regressions.Results: About 397,713 patients were identified including 86,345 (21.7%) aged 80 and above. Octogenarians had higher in-hospital mortality for all procedures: CABG (4.94% vs. 2.39%, p < .001), VHS (5.49% vs. 4.08%, p < .001), and CABG + VHS (7.59% vs. 5.95%, p < .001), and this relationship persisted when gender, race, comorbidities, and type of hospital admission were controlled for: CABG (odds ratio [OR] = 1.71; 95% confidence interval [CI] 1.62-1.81); VHS (OR = 1.18; 95% CI 1.11-1.27); and CABH + VHS (OR = 1.17; 95%CI 1.10-1.26). Female gender, renal, or heart failure, nonelective admission, and CABG + VHS were associated with increased risk of in-hospital mortality. Octogenarians had higher rates of these factors (p < .001). The effect size of renal and heart failure and type of surgery was smaller for octogenarians.Conclusions: Octogenarians undergoing cardiac surgery have higher rates of nonelective admissions, renal and heart failure, and female gender, which are most strongly associated with in-hospital mortality. Differing effect sizes suggest that certain risk factors, such as renal and heart failure, contribute more to mortality in younger patients. [ABSTRACT FROM AUTHOR]

Background: Venoarterial extracorporeal membrane oxygenation (VA-ECMO) can be life-saving in refractory cardiogenic shock but carries a risk of neurologic complications such as stroke and hemorrhage. As little is known about the effects of different peripheral VA-ECMO cannulation sites on cerebral blood flow (CBF), transcranial Doppler (TCD) was used to determine whether the cannulation site affects CBF.Methods: Thirty-seven patients receiving VA-ECMO for cardiogenic shock via axillary or femoral artery cannulation were prospectively enrolled. Measured bilateral middle cerebral artery (MCA), mean flow velocities (MFV), and pulsatility indices (PI) were the primary outcomes and adverse neurologic events were secondary outcomes.Results: The median age was 58 years (IQR 51-66) with 26 (70%) males. Median VA-ECMO flow was 3.8 L/min (IQR 3.2-4.9) with mean arterial pressures of 80 mm Hg (IQR 75-86). Nineteen patients received right axillary artery cannulation while 18 underwent femoral cannulation. Compared with the femoral group, MFV was higher in the axillary group in the right MCA (46 cm/s [IQR 26-57] vs 27 [17-36], P = 0.03) and left (43 [IQR 35-60] vs 29 cm/s [16-48], P = 0.05). Axillary PI was significantly lower compared with the femoral group (right: 0.48 cm/s [0.25-0.65] vs 0.83 [0.66-0.93], P = 0.02; left: 0.41 cm/s [0.29-0.63] vs 1.02 [0.7-1.3], P = 0.004). One axillary patient experienced a stroke with deficits.Conclusions: TCD appears to be an effective tool for indirect monitoring of CBF in patients with ECMO with limited pulsatility. Axillary artery cannulation seems to provide higher cerebral flow rates without any difference in neurologic outcomes. Future studies may incorporate TCD into regulating ECMO flows to achieve physiologic CBF. [ABSTRACT FROM AUTHOR]

Abstract: With the impending United Network for Organ Sharing (UNOS) heart allocation policy giving VA‐ECMO supported heart transplant (HT) candidates highest priority status (Tier 1), identifying patients in cardiogenic shock (CS) with severe and irreversible heart failure (HF) appropriate for urgent HT is critically important. In a center where wait times currently preclude this approach, we retrospectively reviewed 119 patients (ages 18‐72) with CS from 1/2014 to 12/2016 who required VA‐ECMO for >24 hours. Underlying aetiologies included postcardiotomy shock (45), acute coronary syndromes (33), and acute‐on‐chronic HF (16). Eighty‐four percent of patients (100) had ≥1 contraindication to HT with 61.3% (73) having preexisting contraindications (eg, multiorgan dysfunction and substance abuse), and 68.1% (81) experienced preclusive complications (eg, renal failure, coagulopathy, and infection). Potential HT candidates were significantly more likely to survive to discharge (potential HT candidates 84.2% vs preexisting contraindications 43.8% vs contraindications developing on VA‐ECMO 33.3%, P = 0.001). Among potential HT candidates, 11 (68.8%) were discharged without advanced therapies and 4 received durable left ventricular assist device (25.0%). Importantly, 1‐year survival was 100% for the 11 patients with follow‐up. Thus, further work is critical to define appropriate candidates for HT from VA‐ECMO while avoiding preemptive transplantation in those with otherwise favorable outcomes. [ABSTRACT FROM AUTHOR]

Introduction: The development of ventricular assist device (VAD) has been one of the revolutionary advancements in end-stage heart failure management. Although the device has developed and improved significantly over the last few decades, we still face multiple challenges. Areas covered: This review will discuss quality of life, survival, and clinically encountered complications in patients with VAD support. The literature was extensively reviewed for studies describing the above topic area. We describe the impact of major challenges faced in VAD support and discuss their future and expectations. Expert commentary: The technological advancement of VADs has contributed to major improvement of overall survival, enhancement of quality of life and decrease of incidence of complications. It is expected that technologies will continue to evolve. At the same time, the indications for and timing of device implantation, and selection of device type are continuously important in clinical practice setting. [ABSTRACT FROM AUTHOR]

The article focuses on managing massive transfusion protocol (MTP) during cardiopulmonary bypass (CPB) in the setting of penetrating traumatic injury. Topics include the complex decision-making associated with MTP during CPB, the need for optimal transfusion ratios in trauma patients undergoing cardiac surgery, and the importance of randomized multicenter trials to address blood product transfusion ratios during MTP in trauma patients on CPB.

Objective: In the setting of acute aortic syndromes, timely access to definitive surgical repair is of paramount importance. Older patients, primarily septuagenarians and octogenarians, undergoing emergent ascending arch repair experience higher rates of mortality compared to younger patients. Despite this risk, studies show that surgical management is still superior to medical management for this patient population. The objective of this study is to determine if older age impacts the time from presentation to the start of surgery for patients with acute aortic syndromes undergoing surgical repair., Methods: This retrospective review included all patients with acute aortic syndromes who underwent emergent ascending aortic arch repair from January 2018 to May 2023 at a single academic institution. Our analysis compared outcomes for older patients (age 70 years and older) with younger patients (age less than 70 years). Primary outcomes included 30-day mortality, postoperative stay, time from emergency department presentation to the start of surgery, and time from diagnosis with computed tomography to the start of surgery. Secondary outcomes included postoperative complications. Outcomes were analyzed using chi-squared and Student's t-tests, with significance set at p<0.05., Results: Of 107 patients included (male, N=57), 71 (66%) were under the age of 70 and 36 (34%) were 70 years of age or older. The younger cohort had more male and non-White patients, with no differences in rates of hypertension, dyslipidemia, and smoking history. With no difference in the rate of transfers from outside hospitals, we observed longer times from presentation to the start of surgery for older patients compared to younger patients (7 hours and 13 minutes vs. 6 hours 25 minutes; p=0.02) and also for time of diagnosis to the start of surgery (4 hours 22 minutes vs. 3 hours 54 minutes; p=0.006). Older patients had higher rates of intraoperative (0% vs. 17%, p<0.001) and 30-day (7% vs. 44%, p<0.001) mortality. There were no differences in length of stay or in rates of postoperative complications and surgery-related emergency department visits., Conclusions: Patients aged 70 and older experienced delays from the time of presentation to the start of surgery and from time of diagnosis to the start of surgery. Age should not delay an individual from receiving timely transfer to a tertiary center for a higher level of care to better assess the patient's operative candidacy and determine appropriate treatment., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Nithikasem et al.)

Background: Establishing cardiopulmonary bypass remains critical to the successful repair of an acute type A aortic dissection. A recent trend away from femoral arterial cannulation has occurred in part due to concerns of stroke risk from retrograde perfusion to the brain. The purpose of this study was to determine if arterial cannulation site for aortic dissection repair impacts surgical outcomes., Methods: A retrospective chart review was performed at Rutgers Robert Wood Johnson Medical School from January 1st, 2011 to March 8th, 2021. Of the 135 patients included, 98 (73%) underwent femoral arterial cannulation, 21 (16%) axillary artery cannulation, and 16 (12%) direct aorta cannulation. The study variables included demographic data, cannulation site, and complications., Results: The mean age was 63.6±14 years, with no difference between the femoral, axillary, and direct cannulation groups. Eighty-four patients (62%) were male, with similar percentages amongst each group. The rates of bleeding, stroke, and mortality specifically due to the arterial cannulation did not significantly differ based on cannulation site. None of the patients had strokes that were attributable to cannulation type. No patients died as a direct complication of arterial access. The overall in-hospital mortality was 22%, similar between groups., Conclusions: This study found no statistically significant different in rates of stroke or other complications based on cannulation site. Femoral arterial cannulation thus remains a safe and efficient choice for arterial cannulation in the repair of acute type A aortic dissection., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-22-576/coif). The authors have no conflicts of interest to declare., (2023 Journal of Thoracic Disease. All rights reserved.)

Objective: The Impella heart pump is an intravascular microaxial device that provides short-term mechanical circulatory support and can be placed through the femoral, axillary, or central vessels. One of the most feared complications is stroke. It is unclear if patient stroke risk varies based on access vessel. Methods: A retrospective review of consecutive patients who underwent Impella placement at an academic institution from January 1, 2007, through September 15, 2018, was performed. Four groups were compared: (1) minimally invasive Impella (femoral or axillary access), (2) minimally invasive Impella upgraded to another minimally invasive Impella, (3) minimally invasive Impella upgraded to a central Impella (ascending aorta), and (4) central Impella. Patient charts were reviewed to identify baseline characteristics. Outcome measures included length of stay, stroke, and mortality. Results: A total of 349 patients (or 407 Impellas) were identified, and the majority of the devices were inserted through a minimally invasive approach ( n  = 248, 60.9%), while the remainder were implanted via central access ( n  = 159, 39.1%). Minimally invasive Impellas were upgraded in 44 patients. The risk of stroke for the entire cohort was 10.3% ( n  = 36), with no difference observed in any particular group. Overall mortality was 44.4% ( n  = 155). Of the patients who initially received a minimally invasive Impella, those who were upgraded had higher rates of mortality (56.8% vs 39.4%, P  = 0.03), postoperative dialysis (50.0% vs 27.4%, P < 0.01), and sepsis (43.2% vs 20.0%, P < 0.01). Conclusions: This study found no statistically significant difference in rates of postoperative stroke based on initial access vessel.

Background: The optimal cannulation site for repair of type A aortic dissection remains controversial. The concern for Malperfusion syndrome has initiated a national trend away from femoral cannulation to axillary artery and direct ascending aortic cannulation. The purpose of this study was to report a single center experience with femoral artery cannulation for the repair of a type A dissection., Methods: A retrospective study was performed on 52 patients who underwent surgical repair for a type A dissection between January 1 st , 2012 and June 30 th , 2019 at a single institution. Of the 52 patients analyzed, 35 (67.3%) underwent femoral artery, 11 (21.2%) direct ascending aortic, and 6 (11%) axillary artery cannulation for arterial access. Deep hypothermic circulatory arrest was used in all the patients. Rates of postoperative complication and mortality were reported., Results: The mortality and bleeding rates for all the patients undergoing repair of the type A dissection repairs were 27% (14/52) and 19% (10/52), respectively. Cardiopulmonary bypass was established in 100% of the patients that had femoral arterial cannulation. There were no complications specifically related to femoral arterial cannulation nor the axillary or direct aortic approach. Specifically, there was no episodes of malperfusion syndrome, bleeding, or injury with femoral artery cannulation. Bleeding rates were higher in cases that proceeded with a femoral (13%) versus alternate (6%) approach however; neither of the bleeding was related to the cannulation site. None of the mortalities identified were directly attributable to the cannulation approach in each case., Conclusions: Despite the recent shift away from femoral cannulation, the results of the study show that femoral artery cannulation is safe and produces excellent results for establishing cardiopulmonary bypass. The concerns for malperfusion syndrome related to femoral cannulation were not seen., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jtd-20-2549). The authors have no conflicts of interest to declare., (2021 Journal of Thoracic Disease. All rights reserved.)

Objectives: Ethical and health care economic concerns surround the use of venous-arterial extracorporeal membrane oxygenation (VA-ECMO) in elderly patients. Patients requiring VA-ECMO are often in critical condition and the decision to cannulate is time-sensitive. We investigated the relationship between age and VA-ECMO outcomes to better inform this decision., Methods: This is a retrospective study of 355 patients placed on VA-ECMO between March 2007 and August 2016 at our institution. Using piecewise modelling, age became associated with in-hospital mortality after 63 years. Based on further analysis with the χ2 statistic maximization, patients were divided into 2 age groups: ≤72 years old [Group Y (Young), n = 310] and >72 years old [Group O (Old), n = 45]. Multivariable logistic regression was performed to identify preoperative predictors of in-hospital mortality., Results: Patients over the age of 72 had a significantly higher prevalence of comorbidities, including coronary disease, previous strokes and chronic kidney disease. Weaning from ECMO was achieved in 76% of Group Y and 47% of Group O (P < 0.001). In-hospital mortality was 52% among Group Y and 69% among Group O (P = 0.037). Multivariable logistic regression using preoperative risk factors identified coronary artery disease, acute decompensated heart failure and an age >72 years as independent predictors of mortality (age >72 years: odds ratio 2.71, 95% confidence interval 1.22-6.00; P = 0.01)., Conclusions: VA-ECMO in-hospital mortality is considerable across all age groups. However, age only becomes associated with mortality after 63 years and rises dramatically after 72 years. This study provides useful insight into these time-sensitive decisions for the development of possible practice guidelines.

Objectives: There are few reports on the outcome of total arch replacement (TAR) with concomitant coronary artery bypass grafting (CABG); the present study was aimed at analysing outcomes after TAR with CABG at our institute., Methods: Between January 2002 and December 2012, 123 consecutive patients underwent elective TAR with or without CABG. The patients were divided into two groups: 46 who had concomitant CABG (Group T/C) and the rest, who had TAR only (Group T). TAR was performed under mild hypothermic circulatory arrest and selective antegrade cerebral perfusion (SACP) using a four-branched arch graft., Results: The number with a low ejection fraction (<50%) was higher in Group T/C, in which the additive and the logistic EuroSCORE were also higher. The mean number of coronary anastomoses was 1.6 ± 0.8 in Group T/C. The mean durations of surgery (P < 0.01), cardiopulmonary bypass (P < 0.01), cardiac ischaemia (P < 0.01) and SACP (P < 0.01) were significantly longer in Group T/C. The early graft patency of bypass grafts was 96.7%. Between Group T and Group T/C, there were no significant differences in the incidence of stroke (3.9 and 10.9%, P = 0.13), perioperative myocardial infarction (0 and 2.2%, P = 0.37) and in-hospital mortality (2.6 and 8.7%, P = 0.14). There was one case of 30-day mortality in each group. Preoperative haemodialysis, NYHA III/IV and operation time were multivariate predictors (P < 0.05) of in-hospital mortality., Conclusions: Although concomitant CABG in TAR patients had higher operative risk, it can be safely performed with favourable outcomes., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Cardiac papillary fibroelastoma is a rare, benign tumor, arising predominantly from cardiac valves. This tumor can cause a variety of symptoms due to thromboembolism. We describe our single-center surgical experience with papillary fibroelastoma of the aortic valve. From April 2004 through June 2013, 6,530 patients underwent cardiac surgery. Of those, 6,098 patients were included in the final analysis. Twenty-one patients (0.34%) underwent surgical resection of 30 papillary fibroelastomas of the aortic valve. Most patients (67%) were incidentally diagnosed to have cardiac papillary fibroelastoma. The usual symptom was cerebral infarction (in 5 of 7 symptomatic patients). A rare presentation of papillary fibroelastoma in one patient was cardiac arrest caused by left main coronary artery ostial obstruction. Tumor size was not related to patient age (Pearson correlation coefficient, 0.34; P=0.13). Neither the number of tumors (1.43 ± 0.72 vs 1.43 ± 0.62) nor tumor size (8.14 ± 2.42 vs 8.07 ± 3.31 mm) was significantly different between symptomatic and asymptomatic patients. All lesions were resected by means of the simple shave technique. There were no operative or 30-day deaths. Follow-up echocardiograms showed no tumor recurrence (mean follow-up duration, 17 ± 14 mo). We identified no significant relationship among tumor size, number of tumors, symptoms, or patient age. Because simple shave excision of the tumor can be safely achieved without evidence of tumor recurrence, we conclude that surgical resection can be reasonable in asymptomatic patients.