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The Impella 5.5 with Smart Assist (Abiomed) is a life-saving treatment option in acute heart failure which utilizes a continuous heparin purge solution to prevent thrombosis. In patients with contraindications to heparin, alternative anticoagulation strategies are required. We describe the stepwise management of anticoagulation in a coagulopathic patient with persistent cardiogenic shock following a coronary artery bypass procedure who underwent Impella 5.5 placement. A direct thrombin inhibitor-based purge solution was utilized while evaluating for heparin-induced thrombocytopenia. The use of a novel bicarbonate-based purge solution (BBPS) was successfully used due to severe coagulopathy. There were no episodes of pump thrombosis or episodes of severe bleeding on the BBPS and systemic effects of alkalosis and hypernatremia were minimal.

Background The benefit of extracorporeal membrane oxygenation (ECMO) for patients with severe acute respiratory distress from COVID-19 refractory to medical management and lung-protective mechanical ventilation has not been adequately determined. Methods We reviewed the clinical course of 37 patients with laboratory-confirmed SARS-CoV-2 infection supported by venovenous ECMO at four ECMO referral centers within a large healthcare system. Patient characteristics, progression of hemodynamics and inflammatory markers, and clinical outcomes were evaluated. Results The patients had median age of 51 years (interquartile range [IQR] 40-59), and 73% were male. Peak plateau pressures, vasopressor requirements, and arterial PaCO2 all improved with ECMO support. In our patient population, 24/37 patients (64.8%) survived to decannulation and 21/37 patients (56.8%) survived to discharge. Among patients discharged alive from the ECMO facility, 12 patients were discharged to a long-term acute care or rehabilitation facility, 2 were transferred back to the referring hospital for ventilatory weaning, and 7 were discharged directly home. For patients who were successfully decannulated, median length of time on ECMO was 17 days (IQR 10-33.5). Conclusions Venovenous ECMO represents a useful therapy for patients with refractory severe acute respiratory distress syndrome from COVID-19., Graphical abstract

We present a complication following deployment of the MANTA VCD device following a TAVR procedure which resulted in occlusion of the common femoral artery. This was addressed by ballooning the site from the contralateral side which re-established flow. We believe this is the first report to address this kind of complication and may prove useful as more of the MANTA devices are being used in multiple procedures.

Background We present a complication following the deployment of the MANTA vascular closure device (VCD) following a transcatheter aortic valve replacement procedure which resulted in occlusion of the common femoral artery. Aims To address possible complications associated with MANTA VCD. Results This was addressed by ballooning the site from the contralateral side which re-established flow. Conclusion We believe this is the first report to address this kind of complication and may prove useful as more of the MANTA devices are being used in multiple procedures.

Summary Mesenchymal stem cells (MSCs) reportedly exist in a vascular niche occupying the outer adventitial layer. However, these cells have not been well characterized in vivo in medium- and large-sized arteries in humans, and their potential pathological role is unknown. To address this, healthy and diseased arterial tissues were obtained as surplus surgical specimens and freshly processed. We identified that CD90 marks a rare adventitial population that co-expresses MSC markers including PDGFRα, CD44, CD73, and CD105. However, unlike CD90, these additional markers were widely expressed by other cells. Human adventitial CD90+ cells fulfilled standard MSC criteria, including plastic adherence, spindle morphology, passage ability, colony formation, and differentiation into adipocytes, osteoblasts, and chondrocytes. Phenotypic and transcriptomic profiling, as well as adoptive transfer experiments, revealed a potential role in vascular disease pathogenesis, with the transcriptomic disease signature of these cells being represented in an aortic regulatory gene network that is operative in atherosclerosis., Highlights • We identify, in situ and in vivo, adventitial CD90+ MSCs in human arteries • Human adventitial CD90+ cells fulfill all criteria for an MSC population • Other markers, such as CD44 and PDGFRα, were non-specific for adventitial MSCs • The CD90+ MSC transcriptomic signature suggests a major role in vascular disease, MSCs reportedly exist in a specific vascular niche, but these cells have not been well characterized in medium- and large-sized human arteries. To address this, surplus arterial tissues were obtained at surgery and freshly processed. We show that CD90 marks a human adventitial MSC population, with the CD90+ MSC transcriptomic signature being represented in an atherosclerotic regulatory gene network.

Only one case of renal cell carcinoma (RCC) with inferior vena cava (IVC) tumor thrombus diagnosed and treated during pregnancy has been reported in the literature. In that report, the tumor thrombus extended to the infrahepatic IVC (level II tumor thrombus). In the present case, a 37-year-old woman with lupus anticoagulant antibodies was diagnosed with RCC and IVC tumor thrombus extending to the right atrium (level IV tumor thrombus) at 24 weeks of pregnancy. The fetus was safely delivered by cesarean section at 30 weeks of gestation. At 4 days later, an open right radical nephrectomy and IVC and right atrial thrombectomy were performed on cardiopulmonary bypass (CPB) once the patient’s hemodynamic status had been optimized. Fetal and maternal concerns included the risk of a thromboembolic event (due to increased hypercoagulability from pregnancy, active malignancy, and lupus anticoagulant), intraoperative hemorrhage risk (due to extensive venous collaterals and anticoagulation), and fetal morbidity and mortality (due to fetal lung immaturity). Standardized guidelines for treatment of RCC with or without IVC tumor thrombus during pregnancy are unavailable due to the infrequency of such cases. Treatment decisions are therefore individualized and this case report may inform the management of future patients diagnosed with RCC with level IV tumor thrombus during pregnancy.

Objective: Anomalous left coronary artery from the right coronary sinus (ALCA) is a known cause of sudden death. Surgical correction is recommended for all patients with interarterial course. We describe 2 patients who underwent surgical correction through an off pump- minimally invasive direct coronary artery bypass (MIDCAB) approach with good short and mid-term results.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare clinical entity that occurs in a small subset of acute pulmonary embolism (PE) cases and is surgically cured by pulmonary endarterectomy. We report a case of a 44-year-old female with a complex history of CTEPH treated by thromboendarterectomy who presented with a subdural hematoma while on warfarin. The patient eventually recovered by a multidisciplinary approach, use of inferior vena caval filter, and effective anticoagulation management.

Background: The objective of this study was to investigate the association of the coronary SYNTAX score with the degree of atherosclerosis of the ascending aorta in patients who underwent coronary artery bypass grafting (CABG). Methods: A total of 152 patients (mean age 65 years, 66% male) were analyzed who underwent isolated CABG with both SYNTAX score and the intraoperative 5-point scale grading of the severity of atherosclerosis in the ascending aorta available. The patient were stratified into low, intermediate, and high SYNTAX score groups [≤22 (n=36), 22–33 (n=42), and ≥33 (n=76)]. Results: The mean SYNTAX score was 31±11. Patient demographics and comorbidity were comparable in each group. The prevalence of severe atherosclerosis (Grade ≥III) in the ascending aorta was 17.5% (n=27) in the whole population and was different in each group with higher prevalence in higher score groups (8.3% vs . 9.5% vs . 26.3%, P=0.018). After adjusting for age, sex and other relevant comorbidity, SYNTAX score remained a predictor of severe atherosclerosis [adjusted OR 1.63, 95% CI 1.01–2.62, P=0.046 (per 10 point increase); adjusted OR 5.20, 95% CI 1.15–23.5, P=0.032 (high vs . low score)]. Conclusions: SYNTAX score was associated with the severity of atherosclerosis in the ascending aorta. Patients with high scores have a 5 times higher chance of severe disease compared to patients with low scores and should warrant preoperative and intraoperative comprehensive assessment of the ascending aorta.

Surgical pulmonary embolectomy is one of the treatment options for massive pulmonary embolism. At our institute, we have recently adopted a strategy of video assistance for better visualization and clearance of distal pulmonary emboli. Here, we describe our experience.

OBJECTIVES: Many patients referred for coronary artery bypass surgery (CABG) today have diffusely diseased coronary vessels, and some of them may require coronary endarterectomy to provide adequate revascularization. Most reports of coronary endarterectomy describe an on-pump procedure. As off-pump coronary artery bypass graft has become safer and more routine, there is renewed interest in off-pump coronary endarterectomy. We report on our series of patients who underwent off-pump coronary endarterectomy of the left anterior descending (LAD) artery using an open endarterectomy technique. METHODS: All patients undergoing open heart surgery at The Mount Sinai Medical Center are entered into a state-mandated, audited database. A retrospective review of this database revealed 12 patients between January 2008 and June 2012 who underwent off-pump endarterectomy of the LAD as part of their coronary revascularization. Additional data were collected from a review of the patients’ charts. RESULTS: There were a total of 12 patients, with a mean age of 72 ± 4 years. Nine (75%) were male and 3 (25%) were female. Comorbidities included hypertension in 11 (92%) patients, dyslipidaemia in 10 (83%), diabetes in 8 (67%), renal failure in 6 (50%) and stroke in 1 (8%). The mean number of diseased coronary territories was 3 ± 0.4 (range 2–3), and the mean number of coronary bypass grafts performed was 4 ± 0.8 (range 2–5). Eight patients required transfusion with packed red blood cells (67%). One (8%) patient was converted from off-pump to on-pump. The mean intensive care unit stay was 3 ± 2.8 (range 1–8 days), and the mean hospital length of stay was 15 ± 13 (range 4–54 days). Postoperative follow-up (mean 24 ± 19 months, range 1–53) is complete, and no ischaemic events have occurred in the early and mid-term follow-up period. CONCLUSIONS: We conclude that off-pump endarterectomy of the LAD is a viable option for patients with diffuse LAD disease.

Objective: Anomalous right coronary artery arising from the left sinus (ARCA) is a known cause of sudden cardiac death, particularly in young athletes. Surgery is recommended for all adult patients who are symptomatic or who have evidence of exercise-induced myocardial ischemia. Surgical options include coronary artery bypass grafting (CABG) and anatomic correction by unroofing the ostium or by reimplanting the ostium into the right sinus of Valsalva. We describe the rationale and technique of a minimally invasive right thoracotomy approach for correction of ARCA. Methods: We reviewed all patients with coronary artery disease operated upon at Mount Sinai Medical Center. Between March 2008 and September 2010, 17 patients underwent surgery for anomalous coronary origin from the opposite sinus of Valsalva. Nine of these patients had ARCA. We describe four adult patients with ARCA who were operated upon using a small right anterior thoracotomy incision to perform a right internal mammary artery (RIMA) to right coronary artery (RCA) bypass with ligation of the proximal RCA. This was performed under direct vision and without cardiopulmonary bypass. Results: There were two male and two female patients. Mean age was 55.3 4.8 years (range 50—61 years). Three of the patients manifested chest pain and one each syncope, dyspnea, and palpitations. Two patients had preoperative stress testing that was positive for ischemia. Postoperative follow-up (mean 14 months and range 5—37 months) is complete. All patients are alive and asymptomatic. Conclusions: ARCA can be managed with good early and midterm results using a minimally invasive right thoracotomy approach. # 2011 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

OBJECTIVES We sought to examine contemporary utilization patterns and clinical outcomes in patients with acute myocardial infarction (AMI) requiring intra-aortic balloon pump (IABP) counterpulsation. BACKGROUND Despite increasing experience with and broadened indications for intra-aortic counterpulsation, the current indications, associated complications, and clinical outcomes of IABP use in AMI are unknown. METHODS Between June 1996 and August 2001, data were prospectively collected from 22,663 consecutive patients treated with aortic counterpulsation at 250 medical centers worldwide; 5,495 of these patients had AMI. RESULTS Placement of an IABP in AMI patients was most frequently indicated for cardiogenic shock (27.3%), hemodynamic support during catheterization and/or angioplasty (27.2%) or prior to high-risk surgery (11.2%), mechanical complications of AMI (11.7%), and refractory post-myocardial infarction unstable angina (10.0%). Balloon insertions were successful in 97.7% of patients. Diagnostic catheterization was performed in 96% of patients, and 83% underwent coronary revascularization before hospital discharge. The in-hospital mortality rate was 20.0% (38.7% in patients with shock) and varied markedly by indication and use of revascularization procedures. Major IABP complications occurred in only 2.7% of patients, despite median use for three days, and early IABP discontinuation was required in only 2.1% of patients. CONCLUSIONS With contemporary advances in device technology, insertion technique, and operator experience, IABP counterpulsation may be successfully employed for a wide variety of conditions in the AMI setting, providing significant hemodynamic support with rare major complications in a high-risk patient population.

The incidence of esophageal cancer has been steadily increasing in the United States over the past 25 years. Even with standardized surgical techniques, esophagectomy is a complex, multi-phase operation with a wide range of possible complications. The Ivor-Lewis esophagectomy is a commonly used technique where the right gastroepiploic artery (RGEA) becomes the sole source of blood to the stomach. We describe a case of accidental transection of the RGEA which was then re-anastomosed followed by successful use of the gastric conduit. After an acceptable outcome, we suggest that in selected cases anastomosis of the RGEA should be considered.

The left internal mammary artery (LIMA) to the left anterior descending artery bypass remains the gold standard for coronary artery bypass grafting. This review focuses on the three major options for LIMA takedown when using minimal access options to achieve this bypass, namely standard minimally invasive direct coronary artery bypass (MIDCAB), thoracoscopic MIDCAB, and robotically assisted MIDCAB.

Aims To examine differences in patient characteristics and outcomes in 19 636 patients enrolled in the USA and 3027 patients enrolled in other countries undergoing intra-aortic balloon pump (IABP) counterpulsation. Methods and results Indications for IABP use; a larger percentage of US patients were identified as ‘early support and stabilization for angiography or angioplasty’ (21.1% US vs 11.8% non-US), and ‘pre-operative support for high-risk CABG’ (15.9% vs 6.6%). A smaller percentage of US patients vs non-US patients were identified as ‘weaning from cardiopulmonary bypass’ (14.3% vs 28.2%), and ‘refractory ventricular failure’ (6.2% vs 9.8%). One out of five patients in both groups was listed as ‘cardiogenic shock’ (18.9% US vs 20.2% non-US). All cause, risk-adjusted, in-hospital mortality (20.1% vs 28.7%; P

As the proportion of high-risk patients for cardiac surgery increases, use of intraaortic balloon counterpulsation (IABC) has increased, especially in preoperative therapy. Although the efficacy and cost-effectiveness of IABC have been demonstrated, historically higher complication rates have dissuaded some practitioners from using IABC.This report describes IABC use in cardiac surgery, examines trends in complications over time, and compares outcomes in preoperative versus postoperative use in a single prospective worldwide registry over the past 3 years.The frequency of IABC use appears to be increasing with time as the complication rates have dramatically fallen. The overall IABC-related complication rate was 6.5% (460/7,101), and the rate of major complications (requiring surgery or transfusion) was 2.1% (148/7,101). Hospital mortality was significantly lower in patients treated preoperatively with IABC compared with patients treated postoperatively (8.8% vs 28.2%, p0.0001), although this may be due to a selection bias in the postoperative group.Preoperative IABC therapy leads to better patient outcomes in high-risk CABG patients. Improved IABC technology and better surveillance have led to increased use with lower complication rates. Although selection bias is inherent in retrospective studies, the Benchmark Counterpulsation Outcomes Registry outcomes are in close concordance to prospective randomized studies previously reported.

Background . A prospective study was performed assessing the hemodynamic effects of carbon dioxide (CO 2 ) insufflation during endoscopic vein harvesting (EVH) using the Guidant Vasoview Uniport system. Methods . Five hemodynamic and respiratory parameters (end-tidal carbon dioxide, arterial partial pressure of carbon dioxide, mean arterial pressure, mean pulmonary arterial pressure, and cardiac output), were measured in 100 consecutive patients undergoing EVH with CO 2 insufflation. Data were obtained prior to commencement of EVH, 15 minutes after commencement, and 5 minutes after completion of the vein harvesting. Results . No adverse hemodynamic effects were observed during CO 2 insufflation. Specifically, average mean arterial pressure went from 88.77 ± 9.64 to 89.13 ± 8.60 to 88.24 ± 8.71 mm Hg before, during, and after endoscopic vein harvesting ( p = 0.291). Likewise, average mean pulmonary artery pressures were 19.76 ± 4.75, 20.05 ± 4.48, and 20.05 ± 4.62 mm Hg ( p = 0.547); and average cardiac output was 4.25 ± 0.74, 4.22 ± 0.73, and 4.23 ± 0.69 L/min ( p = 0.109) at those three intervals. Additionally, there was no evidence of significant systemic absorption of CO 2 as reflected in average arterial Pco 2 , which remained steady at 37.42 ± 5.19, 37.51 ± 4.59, and 38.10 ± 4.80 mm Hg ( p = 0.217); and average end-tidal CO 2 , which was 32.10 ± 3.66, 32.50 ± 3.47, and 32.38 ± 3.33 mm Hg ( p = 0.335). In a subset of 20 patients with elevated pulmonary arterial pressure (more than 32 mm Hg), there was also no significant change in any of the parameters. Conclusions . Carbon dioxide insufflation during EVH leads to no adverse hemodynamic consequences or systemic CO 2 absorption. The technique appears to be safe and well tolerated.