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Transcatheter aortic valve replacement (TAVR) has become the preferred intervention for patients with severe aortic stenosis and significant comorbidities. This technique can also be used for failed bioprosthetic valves and is known as the valve-in-valve (ViV) procedure. Placing TAVR in a small bioprosthesis (23 mm) can lead to delayed dysfunction of the prosthetic valve. We present a case of a late explanted ViV 8 years post-initial aortic valve replacement and coronary artery bypass grafting, and 3 years post-ViV procedure in a 76-year-old female. A video of the surgical procedure is provided.

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.

We report a case of Impella 5.5-assisted off-pump coronary artery bypass grafting for acute myocardial infarction with cardiogenic shock. The Impella 5.5 was placed in the left ventricle during the emergent procedure, and an off-pump coronary artery bypass grafting was successfully performed with exposure of all three walls of the heart. Our findings demonstrated the feasibility of off-pump coronary revascularization in three-vessel disease in a patient assisted with an Impella 5.5 percutaneous left ventricular assist device without displacement of the device during the entire perioperative period.

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.

Objective It is a common situation after cardiothoracic surgery that a tracheostomy is required for patients who are coagulopathic or on therapeutic anticoagulation. We present our results of percutaneous tracheostomy with uncorrected coagulopathy. Methods Between 2007 and 2012, a total of 149 patients in our Cardiothoracic Surgical Intensive Care Unit underwent percutaneous tracheostomy using the Ciaglia Blue Rhino system (Cook Medical, Bloomington, IN USA). The patients were divided into coagulopathic (platelets, ≤50,000; international normalized ratio of prothrombin time, ≥1.5; and/or partial thromboplastin time, ≥50) and noncoagulopathic groups. Coagulopathy, if present before percutaneous tracheostomy, was not routinely corrected. Results A total of 75 patients (49%) were coagulopathic. Twenty-one patients (14%) had two or more criteria. The coagulopathic patients had a lower platelet count [108 (106) vs 193 (111) (thousands), P < 0.001], with the lowest of 10; higher international normalized ratio of prothrombin time [1.7 (0.6) vs 1.2 (0.1), P < 0.001], with the highest of 5.3; longer partial thromboplastin time [40 (13) vs 33 (7) seconds, P < 0.001], with the longest of 85; and higher total bilirubin [4.6 (7.3) vs 1.9 (3.3) mg/dL, P = 0.005]. Patient demographics and comorbidities were comparable between the groups. No patients had overt bleeding. One coagulopathic patient (1.3%) had clinical oozing treated with packing, as opposed to zero in the noncoagulopathic patients ( P = 1.00). There were no patients with posttracheostomy mediastinitis or late tracheal stenosis. Conclusions Uncorrected coagulopathy and therapeutic anticoagulation did not increase bleeding risk for percutaneous tracheostomy in our cardiothoracic surgical patients.

Minimally invasive direct coronary artery bypass grafting (MIDCAB) uses a small anterior left thoracotomy incision and harvesting of the left internal mammary artery with an anastomosis performed to the left anterior descending artery without cardiopulmonary bypass. There is renewed interest in minimally invasive coronary surgery and hybrid revascularization. This article describes a standardized approach that has been consistently successful in our institution.

Off pump coronary artery bypass grafting remains an important technique particularly in the care of high-risk patients. Consistently successful adoption of this technique requires a cooperative team approach and standardization across all phases of patient care. This review describes our approach to off pump coronary surgery.

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 Benchmark Counterpulsation Outcomes Registry is a computerized database that incorporates prospectively gathered data on indications for intra-aortic balloon counterpulsation (IABP) use, patient demographics, concomitant medications and in-hospital complications and outcomes. This report summarizes the validation of the Benchmark Registry. Three audits were performed on the Registry data – the first by the sponsor and the second two by independent auditors. The data for categorical variables that could be answered by checking a box were extremely robust, with most items having at least a 95% agreement rate (except catheter size, which had an 82% agreement rate). The data were slightly less robust for quantitative variables that required a written answer (at least an 80% agreement rate). This high agreement rate supports the conclusion that the Benchmark Counterpulsation Outcomes Registry data are generalizable and suggests that the Registry is a powerful tool for tracking the evolving practice of IABP use, including indications, insertion characteristics, duration, complications and outcomes in patients undergoing IABP.

The Benchmark intra-aortic balloon counterpulsation (IABC) registry maintains prospectively gathered clinical information on a large cohort of IABC patients. The purpose of the present report is to compare in-hospital outcomes and complications in patients treated with the newer 8 vs. 9.5 Fr size catheters. Between January 1997 and August 2000, data on 7,078 9.5 Fr and 2,254 8 Fr IABC insertions were submitted to Benchmark. This was not a randomized comparison but rather a posthoc analysis of prospectively gathered data. There was less limb ischemia with the 8 Fr IABC size catheter. There were no significant differences in bleeding or mortality between the two groups. Smaller IABC catheter size is associated with significantly less limb ischemia, especially in higher-risk patients. The large, population-based, ongoing Benchmark registry provides a useful vehicle for outcomes research concerning the evolving practice of IABC.

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 hypothesis tested in these studies was that long-term circulatory support with a nonpulsatile device is safe and causes no end organ dysfunction. An inexpensive, small centrifugal pump with a 7 L/min capacity was implanted in 6 sheep (15 acute implants have previously been reported). The inlet cannula was placed in the left atrium and the outlet graft anastomosed to the descending aorta. A percutaneous cable supplied DC power and heparinized saline (10 ml/hr) for lubrication. Outputs of pump flow, stator, animal core temperature, pump power consumption, and RPM were monitored throughout the course of each experiment. The sheep moved freely within a large pen using an overhead swivel/tether system that carried all input and output lines. Four sheep survived longer than 4 weeks, and the indices of end organ function were analyzed at 28 days. No animal revealed any neurologic dysfunction. Hemoglobin was 9.075 +/- 0.78 g/dl at 28 days, as opposed to 7.475 +/- 0.68 (p = 0.002) before surgery. The blood urea nitrogen was 9.250 +/- 4.57 versus 14 +/- 5.72 mg/dl (p = 0.041), creatinine was 0.775 +/- .10 versus 0.775 +/- 0.05 mg/dl (p > or = 0.999), total bilirubin was 0.425 +/- 0.2 versus 0.225 +/- 0.05 mg/dl (p = 0.092), serum glutamic oxaloacetic transaminase was 74.75 +/- 24 versus 106.25 +/- 15.84 IU/L (p = 0.015), serum glutamic pyruvic transaminase was 36 +/- 28.7 versus 28.3 +/- 5.7 IU/L (p = 0.25), and total protein was 6.675 +/- 0.49 versus 5.47 +/- 0.15 g/dl (p = 0.025). It is concluded that these animals adapted very well to pulseless circulatory support. The results of these studies support the concept of an inexpensive, implantable, centrifugal pump as a ventricular assist device.