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Background : Acute ischemic stroke (AIS) following left ventricular assist device (LVAD) implantation is a serious complication associated with device morbidity. AIS development following LVAD placement typically presents between 6- and 24-months post implantation. Case/Results : We report a case of a 67-year-old male who initially presented with reduced ejection fraction and severe coronary vessel disease. Following coronary artery bypass graft surgery, the patient remained in a low output state necessitating placement of an LVAD device. Approximately 4.5 hours following LVAD implantation, a severe acute decrease in mental status revealed new development of ischemic stroke of the basilar artery, which was successfully treated in one pass with catheter endovascular thrombectomy. Conclusion : While embolic stroke management in these cases remains difficult as patients are usually anticoagulated, our case demonstrates the utilization of endovascular thrombectomy as a viable therapeutic option in the setting of an uncommon occurrence of embolic stroke in the hours following LVAD implantation. [ABSTRACT FROM AUTHOR]

Background: We describe a technique to assess blood flow distal to the decannulation site after deployment of Perclose ProGlide (Abbott Vascular, Abbott Park, Ill) in patients on femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. Technique: An antegrade distal perfusion catheter was placed in all patients, and decannulation was primarily performed at bedside (N = 11/12). With the VA-ECMO circuit switched off, a needle was inserted into the arterial tubing, passed through the femoral arterial cannula into the artery. The arterial cannula was removed over a wire and the previously placed Proglide Perclose sutures were secured. Back bleeding from the antegrade distal perfusion catheter, confirmed using a three-way connector, indicated blood flow to the superficial femoral artery. This was followed by confirmation of blood flow to the lower leg using a Doppler ultrasound. Hemostasis of the antegrade perfusion catheter was achieved through manual compression. Results: We implemented this technique in 12 patients with a technical success rate of 100%. There were no ipsilateral leg ischemia, bleeding, pseudoaneurysm, or infection after decannulation. Conclusions: This technique allows prompt assessment of blood flow to the distal leg immediately following arterial decannulation. [ABSTRACT FROM AUTHOR]

Background: Cardiac surgery is considered a contraindication in patients with advanced liver cirrhosis (LC) due to increased mortality and morbidity. There are limited data on the treatment strategy and management of this population. We aimed to present our strategy and evaluate the clinical outcome of cardiac surgery in patients with LC. Methods: Our strategy was (i) to list patients for liver transplant (LT) at the time of cardiac surgery; (ii) to maintain high cardiopulmonary bypass (CPB) flow (index up to 3.0 L/min/m2) based on hyper‐dynamic states due to LC; and (iii) to proceed to LT if patients' liver function deteriorated with an increasing model for end‐stage liver disease Na (MELD‐Na) score after cardiac surgery. Thirteen patients (12 male and 1 female [mean age, 63.0]) with LC who underwent cardiac surgery between 2017 and 2024 were retrospectively analyzed. Results: Six patients were listed for LT. Indications for cardiac surgery included coronary artery disease (N = 7), endocarditis (N = 2), and tricuspid regurgitation (N = 1), tricuspid stenosis (N = 1), mitral regurgitation (N = 1), and hypertrophic obstructive cardiomyopathy (N = 1). The Child–Pugh score was A in five, B in six, and C in one patient. The procedure included coronary artery bypass grafting (N = 6), single valve surgery (mitral valve [N = 2] and tricuspid valve [N = 1]), concomitant aortic and tricuspid valve surgery (N = 2), and septal myectomy (N = 1). Two patients had a history of previous sternotomy. The perfusion index during CPB was 3.1 ± 0.5 L/min/m2. Postoperative complications include pleural effusion (N = 6), bleeding events (N = 3), acute kidney injury (N = 1), respiratory failure requiring tracheostomy (N = 2), tamponade (N = 1), and sternal infection (N = 1). There was no in‐hospital death. There was one remote death due to COVID‐19 complication. Preoperative and postoperative highest MELD‐Na score among listed patients was 15.8 ± 5.1 and 19.3 ± 5.3, respectively. Five patients underwent LT (1, 5, 8, 16, and 24 months following cardiac surgery) and one patient remains on the list. Survival rates at 1 and 3 years are 100% and 75.0%, respectively. Conclusion: Cardiac surgery maintaining high CPB flow with LT backup is a feasible strategy in an otherwise inoperable patient population with an acceptable early and midterm survival when performed in a center with an experienced cardiac surgery and LT program. [ABSTRACT FROM AUTHOR]

Background: The axillary artery (AX) access for intra‐aortic balloon pump (IABP) as a bridge to heart transplant (HT) allows mobility while awaiting a suitable donor. As end‐stage heart failure patients often have an implantable cardioverter defibrillator (ICD) on the left side, the left AX approach may be avoided due to the perception of difficult access and proximity of two devices. We aimed to evaluate the outcomes of patients bridged to HT with a left‐sided AX IABP with or without ipsilateral ICDs. Methods: We retrospectively reviewed HT candidates at our institution supported by left‐sided axillary IABP from November 2019 to February 2024, dividing them into two groups based on the presence (Group ICD, n = 48) or absence (Group No‐ICD, N = 19) of an ipsilateral left‐sided ICD. The exposure time was defined as the time from skin incision to the beginning of anastomoses of a Dacron graft. Results: Technical success was achieved in 100% of the cohort, with median exposure times for AX access similar between groups (ICD, 12 [7.8, 18.2] vs. No ICD, 11 [7, 19] min; p = 0.75). The rate of procedural adverse events, such as significant access site bleeding and ipsilateral limb ischemia, did not significantly differ between both groups. Device malfunction rates were comparable (ICD, 29.2% vs. No ICD, 15.8%; p = 0.35). Posttransplant, in‐hospital mortality, severe primary graft dysfunction, and stroke rates were comparable in both groups. Conclusion: The presence of an ipsilateral left‐sided ICD does not adversely impact the procedural efficacy, complication rates, or posttransplant outcomes of left‐sided AX IABP insertion in HT candidates. [ABSTRACT FROM AUTHOR]

Severe mitral regurgitation (MR) is an important cause of acute heart failure and significant contributor to morbidity and mortality. Mechanical circulatory support (MCS) devices such as Impella are readily used to hemodynamically stabilize patients with cardiogenic shock (CS) secondary to this valvular pathology. Impella can also be combined with VA-ECMO to an "ECPELLA" configuration if further escalation of hemodynamic support is needed. We report a case of a 57-year-old female who presented with CS secondary to a perforated anterior mitral valve leaflet and non-ischemic cardiomyopathy that did not stabilize with initial choice of Impella 5.5. She required further escalation from axillary Impella 5.5 to the combined ECPELLA configuration, which allowed hemodynamic stabilization and ultimately a successful high-risk isolated mitral valve replacement. Despite adequate Impella flow, escalation to a combined MCS configuration, such as ECPELLA, may need to be considered upfront for acute valvular insufficiency in the setting of pre-existing cardiomyopathy. [ABSTRACT FROM AUTHOR]

Background: With the growing population of advanced heart failure, the use of Impella 5.5 has been increasing. Here, we report an effective strategy of removing the intra-aortic balloon pump (IABP) in the setting of escalation of support to Impella 5.5. Results: From January 1, 2022 to June 30, 2022, a total of 6 patients have undergone IABP removal during Impella 5.5 insertion. The IABP was subsequently removed over the long wire with manual compression on the femoral artery to control bleeding. An 8 or 9 Fr short sheath is inserted over the wire. Staged hemostasis was successfully performed in 4 patients, and the remaining two patients required escalation of support to veno-arterial membrane oxygenation as EC-PELLA utilizing the femoral arterial sheath. Conclusion: This does not only achieve secured hemostasis but also enables a smooth transition to further escalate support such as extracorporeal membrane oxygenation support, if necessary. [ABSTRACT FROM AUTHOR]

Background: The management of complex groin wounds following VA‐ECMO after heart transplant (HT) is uncertain due to limited experience. Sartorius muscle flaps (SMF) have been used in vascular surgery for groin wound complications. However, their use in HT recipients with perioperative VA‐ECMO is unclear. This study aims to describe characteristics and outcomes of HT patients with groin complications after arterial decannulation for femoral VA‐ECMO. Methods: We retrospectively reviewed HT patients who underwent peri‐transplant femoral VA‐ECMO at our institution from April 2011 to February 2023. Patients were categorized into two groups based on the presence of cannulation‐related wound complications. Results: Among the 34 patients requiring VA‐ECMO peri‐transplant, 17 (50%) experienced complications at the cannulation site. Baseline characteristics including duration of VA‐ECMO support were comparable in both groups. Patients with complications presented mostly with open wounds (41.1%) after a median duration of 22 days post‐transplant. Concurrent groin infections were observed in 52.3% of patients, all caused by gram‐negative bacteria. Wound complications were managed with 12 (70.6%) undergoing SMF treatment and 5 (31.2%) receiving conventional therapy. Four SMF recipients had preemptive procedures for wound dehiscence, while eight underwent SMF for groin infections. Among the SMF group, 11 patients had favorable outcomes without recurrent complications, except for one patient who developed a groin infection with pseudoaneurysm formation. Conventional therapy with vacuum assisted closure (VAC) and antibiotics were utilized in four patients without infection and one patient with infection. Three patients required additional surgeries with favorable healing of the wound. Conclusion: Complications related to femoral VA‐ECMO are common in HT patients, with infection being the most frequent complication. SMFs can be a useful tool to prevent progression of infection and improve local healing. [ABSTRACT FROM AUTHOR]

Background: The advent of direct‐acting antivirals has helped to increase the safe utilization of organs from hepatitis C virus positive (HCV+) donors. However, the outcomes of heart transplantation (HT) using an HCV+ donor are unclear in recipients with underlying liver disease represented by an elevated model for end‐stage liver disease excluding international normalized ratio (MELD‐XI). Methods: The United Network of Organ Sharing database was queried from Jan 2016 to Dec 2021. Post‐transplant outcomes stratified by recipient MELD‐XI score (low <10.37, medium, 10.38–13.39, and high >13.4) was compared between patients with HT from HCV+ (N = 792) and patients with HT from HCV‐negative donors (N = 15,266). Results: The median MELD‐XI score was comparable (HCV+, 12.1, vs. HCV‐negative, 11.8, p =.37). In the HCV+ group, donors were older (33 vs. 31 years, p <.001). Ischemic time of donor hearts (3.48 vs. 3.28 h, p <.001) and travel distance (250 vs. 157 miles, p <.001) were longer in HCV+ group. In the Kaplan Meier analysis with a median follow‐up of 750 days, survival was comparable between the two groups (2‐year survival, MELD‐XI Low: HCV+, 92.4 ± 3.6% vs. HCV‐negative, 91.1 ±.8%, p =.83, Medium: HCV+ 89.2 ± 4.3% vs. HCV‐negative, 88.2 ± 1.0%, p =.68, and High: HCV+, 84.9 ± 4.5% vs. HCV‐negative, 84.6 ± 1.1%, p =.75) In multivariate Cox hazard models, HCV donors were not associated with mortality in each MELD‐XI subgroup (Low: adjusted hazard ratio (aHR), 1.02, p =.94; Medium: aHR,.95, p =.81; and High: aHR,.93, p =.68). Conclusion: Utilization of HCV+ hearts was not associated with an increased risk of adverse outcomes in recipients with an elevated MELD‐ XI score. [ABSTRACT FROM AUTHOR]

Cardiogenic shock is a critical condition of low cardiac output resulting in insufficient systemic perfusion and end-organ dysfunction. Though significant advances have been achieved in reperfusion therapy and mechanical circulatory support, cardiogenic shock continues to be a life-threatening condition associated with a high rate of complications and excessively high patient mortality, reported to be between 35% and 50%. Extracorporeal membrane oxygenation can provide full cardiopulmonary support, has been increasingly used in the last two decades, and can be used to restore systemic end-organ hypoperfusion. However, a paucity of randomized controlled trials in combination with high complication and mortality rates suggest the need for more research to better define its efficacy, safety, and optimal patient selection. In this review, we provide an updated review on VA-ECMO, with an emphasis on its application in cardiogenic shock, including indications and contraindications, expected hemodynamic and echocardiographic findings, recommendations for weaning, complications, and outcomes. Furthermore, specific emphasis will be devoted to the two published randomized controlled trials recently presented in this setting. [ABSTRACT FROM AUTHOR]

Background: Little is known about safety and efficacy of the use of Impella 5.5 compared to previous iterations in the setting of Impella with Veno‐Arterial Extracorporeal Membrane Oxygenation Support as ECPELLA. Methods: Consecutive patients who were treated by ECPELLA with surgically implanted axillary Impella 5.5 (N = 13) were compared with patients supported by ECPELLA with percutaneous femoral Impella CP or 2.5 (Control, N = 13). Results: The total ECPELLA flow was higher in ECPELLA 5.5 group (6.9 vs. 5.4 L/min, p = 0.019). Actual hospital survival was higher than predicted and comparable in both groups (ECPELLA 5.5, 61.5% vs. Control, 53.8%, p = 0.691). Both total device complications (ECPELLA 5.5, 7.7% vs. Control, 46.1%, p = 0.021) and Impella‐specific complications (ECPELLA 5.5, 0% vs. Control, 30.8%, p = 0.012) were significantly lower in the ECPELLA 5.5 group. Conclusions: Utilization of Impella 5.5 in the setting of ECPELLA provides greater hemodynamic support with a lower risk of complications compared to Impella CP or 2.5. [ABSTRACT FROM AUTHOR]

The article describes an episode of severe intraoperative hypotension caused by an acute occlusion of the left main coronary ostium by a mobile vegetation branching off a prosthetic aortic valve, which was visualized by transeosophageal echocardiography (TEE). Topics include clinical characteristics of myocardial ischemia caused by a vegetation and the utility of TEE in diagnosing and managing acute intraoperative hypotension.

Direct heart transplant from veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support is challenging. Continuation of postoperative VA-ECMO support may be required in the setting of primary graft dysfunction or severe vasoplegia. We describe a simple technique to perfuse the ipsilateral leg of an arterial ECMO cannula during heart transplant while the ECMO circuit is turned off but maintaining the arterial cannula and distal perfusion catheter in place. This technique minimizes the number of intraoperative procedures with a minimal risk of leg ischemia, and provides a smooth transition to postoperative VA-ECMO support if necessary. [ABSTRACT FROM AUTHOR]

Background: In heart transplantation (HT), peripheral veno‐arterial extracorporeal membranous oxygenation (VA‐ECMO) is utilized preoperatively as a direct bridge to HT or postoperatively for primary graft dysfunction (PGD). Little is known about wound complications of an arterial VA‐ECMO cannulation site which can be fatal. Methods: From 2009 to 2021, outcomes of 80 HT recipients who were supported with peripheral VA‐ECMO either preoperatively or postoperatively were compared based on the site of arterial cannulation: axillary (AX: N = 49) versus femoral artery (FA: N = 31). Results: Patients in the AX group were older (AX: 59 years vs. 52 years, p =.006), and less likely to have extracorporeal cardiopulmonary resuscitation (0% vs. 12.9%, p =.040). Survival to discharge (AX, 81.6% vs. FA. 90.3%, p =.460), incidence of stroke (10.2% vs. 6.5%, p =.863), VA‐ECMO cannulation‐related bleeding (6.1% vs. 12.9%, p =.522), and arm or limb ischemia (0% vs. 3.2%, p =.816) were comparable. ECMO cannulation‐related wound complications were lower in the AX group (AX, 4.1% vs. FA, 45.2%, p <.001) including the wound infections (2.0% vs. 32.3%, p <.001). In FA group, all organisms were gram‐negative species. In univariate logistic regression analysis, AX cannulation was associated with less ECMO cannulation‐related wound complications (Odds ratio,.23, p <.001). There was no difference between cutdown and percutaneous FA insertion regarding cannulation‐related complications. Conclusions: Given the lower rate of wound complications and comparable hospital outcomes with femoral cannulation, axillary VA‐ECMO may be an excellent option in HT candidates or recipients when possible [ABSTRACT FROM AUTHOR]