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OBJECTIVES Myocardial recovery allows for left ventricular assist device (LVAD) explantations after long-term support. Several surgical approaches, including interventional decommissioning, off-pump explantation using a custom-made plug and complete LVAD removal through redo sternotomy, have been described. We present the results from an evaluation of the long-term follow-up of patients who received a titanium sintered plug after LVAD explantation. METHODS We performed a retrospective, European, multicentre analysis of patients who received a titanium sintered plug to seal the apical fixation ring after LVAD explantation. Data were collected from a questionnaire that included demographics, procedural details and follow-up information. RESULTS Out of 54 contacted centres in 12 countries (n = 179 patients), a total of 68 patients were successfully included in the study. The median follow-up was 34 months (interquartile range: 17–58.5 months); 57 (84%) patients had >1-year follow-up. At the time of the last follow-up, 55 (81%) patients were alive, with a Kaplan–Meier 1-year survival of 90.1% (95% confidence interval: 84.0–98.1%) and a 5-year survival of 80.0% (95% confidence interval: 68.4–92.9%). One patient (1.5%) developed a plug infection originating from an infected part of the incorporated driveline and, after complete removal, is currently in good condition. No postoperative stroke has been reported after plug implantation. CONCLUSIONS In this European multicentre study, the use of a custom-made titanium plug to close the apical fixation ring after LVAD explantation resulted in a low incidence of plug-related complications. With the volume of patients undergoing LVAD explantations after myocardial recovery increasing, the plug has evolved as a simple alternative to more invasive device explantation procedures or decommissioning with a high risk for infection of the remaining system or stroke., Interactive Cardiovascular and Thoracic Surgery, 34 (4), ISSN:1569-9293, ISSN:1569-9285

Transcatheter mitral valve replacement carries a risk of left ventricular outflow tract obstruction associated with mortality. We present a case of left ventricular outflow tract obstruction that resolved spontaneously when chords to the anterior mitral leaflet were found to have ruptured. (Level of Difficulty: Advanced.), Central Illustration

OBJECTIVESLarge series of percutaneous femoral access for extracorporeal circulation in minimally invasive cardiac surgery (MICS) are scarcely reported.METHODSThis is a single-centre study describing the use of percutaneous femoral access in patients undergoing MICS via minithoracotomy. Femoral artery closure was performed with a plug-based closure device. To reduce the risk for vascular complications, intraoperative ultrasound assessment of correct deployment of the arterial closure device was done during the later period of the study.RESULTSDuring a 5-year period, 650 patients underwent percutaneous femoral cannulation and decannulation with device closure of the femoral artery puncture. Two hundred and seven patients (31.8%) were operated in the early phase of the experience (August 2017–August 2019), without the use of intraoperative ultrasound assessment of closure device deployment. During the later period of our experience (August 2019–September 2022), 443 patients (68.2%) were operated, of whom all underwent intraoperative ultrasound assessment of closure device deployment. Of the patients operated without intraoperative ultrasound assessment, 6 patients (2.9%) experienced vascular complications compared with none of the patients in whom intraoperative ultrasound-assessment was used (P CONCLUSIONSPercutaneous femoral access in MICS is safe and the need for surgical cutdown was infrequent. The risk for vascular complications is minimized with the use of intraoperative ultrasound assessment of the correct positioning of the vascular closure device.CLINICAL TRIAL REGISTRATION NUMBERhttp://www.clinicaltrials.gov; Unique identifier: NCT05462769.

OBJECTIVES An increasing number of mitral valve operations are performed using minimally invasive procedures. The initiation of a minimally invasive mitral valve surgery programme constitutes a unique opportunity to study outcome differences in patients with similar characteristics operated on through a sternotomy versus a minimally invasive procedure. The goal of this study was to compare short-term outcomes of patients undergoing mitral valve surgery before versus those having surgery after the introduction of a minimally invasive programme. METHODS The single-centre study included mitral valve procedures performed through a sternotomy or with a minimally invasive approach between January 2012 and May 2019. Propensity score matching was performed to reduce selection bias. RESULTS A total of 605 patients (294 sternotomy, 311 minimally invasive) who underwent mitral valve surgery were included in the analysis. Propensity score matching resulted in 251 matched pairs. In the propensity score-matched analysis, minimally invasive procedures had longer extracorporeal circulation duration (149 ± 52 vs 133 ± 57 min; P = 0.001) but shorter aortic occlusion duration (97 ± 36 vs 105 ± 40 min, P = 0.03). Minimally invasive procedures were associated with a lower incidence of reoperation for bleeding (2.4% vs 7.2%; P = 0.012), lower need for transfusion (19.1% vs 30.7%; P = 0.003) and shorter in-hospital stay (5.0 ± 2.7 vs 7.2 ± 4.6 days; P CONCLUSIONS Minimally invasive mitral valve surgery was associated with short-term outcomes comparable to those with procedures performed through a sternotomy. Initiating a minimally invasive mitral valve programme with a limited number of surgeons and a well-executed institutional selection strategy did not confer an increased risk for adverse events.

Minimally invasive mitral valve surgery requires femoral artery cannulation for extracorporeal circulation, predominantly performed through surgical cutdown. Surgical groin incision is frequently associated with complications such as seroma and infection. We evaluated the safety and efficacy of a percutaneous plug-based large-bore vascular closure device (VCD) for femoral artery closure in minimally invasive mitral valve surgery.This was a single-center prospective study comparing patients undergoing minimally invasive mitral valve surgery with femoral cannulation performed either through surgical cutdown or percutaneously with access site closure using a plug-based VCD (MANTA; Teleflex/Essential Medical, Malvern, PA).From 2016 to 2018, a total of 268 (147 surgical cutdown, 121 VCD) patients underwent minimally invasive mitral valve surgery with femoral arterial cannulation of catheters sized 19-F or 21-F. Propensity score matching resulted in 109 matched pairs. In both the overall series and the propensity-matched cohort, VCD patients had a significantly higher incidence of Valve Academic Research Consortium-2 major access site vascular complications (overall cohort: 0% vs 4.1%; P = .013; propensity score-matched cohort: 0% vs 4.6%; P = .024). Bleeding did not occur in any group. In the overall series, surgical cutdown patients had a higher incidence of seroma (10.9% vs 0%; P.001). Infection and seroma did not occur in the VCD group.Percutaneous femoral artery cannulation using a novel plug-based VCD in minimally invasive mitral valve surgery eliminates traditional complications frequently seen with surgical cutdown with no femoral access site seroma and infection though at the expense of an increased risk for vascular complications.

Purpose Use of a special designed plug is one of the recommended methods for LVAD explantation in case of myocardial recovery (IIa in EACTS expert opinion). The study presents the results from the evaluation of the long-term follow up in patients that received a titanium sintered plug after LVAD explantation. Methods In this retrospective, multi-center analysis 67 patients were enrolled who received a titanium sintered plug after LVAD explantation. Information were collected through a questionnaire containing questions about demographics, surgical procedure and the follow-up. Results Date of last follow-up was successfully recorded for 67 patients and was measured in months. The mean follow-up was 29±27 months; 64% of patients presented > 1 year follow up. At the time of the last follow-up 82% of patients were alive, one patient developed plug infection due to infected part of incorporated driveline. Conclusion In this multicenter study, the use of an individually manufactured titanium plug to close the opening of the apex after LVAD explantation resulted in low incidence of plug-related complications. With the volume of patient undergoing an LVAD explantation after myocardial recovery increasing, the need of industry manufactured plugs is evident.

Minimally invasive cardiac surgery such as a mitral valve procedure requires femoral arterial cannulation for extracorporeal circulation. To avoid complications associated with surgical groin incisions, such as seromas and infections, percutaneous cannulation techniques can be used. This video tutorial illustrates percutaneous femoral cannulation and decannulation using a plug-based vascular closure device.

OBJECTIVES Carbon dioxide (CO2) gas insufflation is used for continuous de-airing during open heart surgery. The aim was to evaluate if an additional separate venous reservoir eliminates CO2 insufflation-induced hypercapnia and keeps sweep gas flow of the oxygenator constant. METHODS A separate reservoir was used during cardiopulmonary bypass in addition to a standard venous reservoir. The additional reservoir received drained blood and CO2 gas continuously via a suction drain (1 l/min) and handheld suction devices from the surgical wound. CO2 gas was insufflated via a gas diffuser in the open wound at 10 l/min. In a cross-over design for each patient, gas and blood were either continuously drained from the additional to the standard venous reservoir or not. CO2 pressure in arterial blood (PaCO2) was measured after adjustment of sweep gas flow as necessary and after steady state of PaCO2 was observed. Mean values for each setup (median 4 times) for each patient were analysed with Wilcoxon rank-sum test. RESULTS Ten adult patients undergoing open aortic valve replacement were included. Median PaCO2 did not differ between setups (5.41; 5.29–5.57, interquartile range vs 5.41; 5.24–5.58, P = 0.92), whereas sweep gas flow (l/min) was lower (2.58; 2.50–3.16 vs 4.42; 4.0–5.40, P = 0.002) when CO2 gas was not drained from the additional to the standard reservoir. CONCLUSIONS An additional venous reservoir for the evacuation of blood from the open surgical wound eliminates CO2 insufflation-induced hypercapnia in open heart surgery keeping PaCO2 and sweep gas flow constant. This prevents possible CO2-induced hyperperfusion of the brain and decreases the risk of cerebral particulate embolization during CO2 insufflation for de-airing in open heart surgery. Clinical trial registration NCT04202575. IRB approval dat and number 2018-07-13 and 2018/1091-31.

Bilateral internal mammary artery (BIMA) grafting is increasingly used in the elderly without evidence of its risks or benefits compared to single internal mammary artery (SIMA) grafting. Background. Bilateral internal mammary artery (BIMA) grafting is increasingly used in elderly patients without evidence of its risks or benefits compared with single internal mammary artery (SIMA) grafting.Methods. In all, 2,899 patients aged 70 years or older (855 [29.5%] underwent BIMA grafting) operated on from January 2015 to December 2016 and included in the prospective multicenter Outcome After Coronary Artery Bypass Grafting (E-CABG) study were considered in this analysis.Results. One-to-one propensity matching resulted in 804 pairs with similar preoperative risk profile. Propensity score matched analysis showed that BIMA grafting was associated with a nonstatistically significant increased risk of inhospital death (2.7% versus 1.6%, p = 0.117). The BIMA grafting cohort had a significantly increased risk of any sternal wound infection (7.7% versus 5.1%, p = 0.031) as well as higher risk of deep sternal wound infection/mediastinitis (4.0% versus 2.2%, p = 0.048). The BIMA grafting cohort required more frequently extracorporeal membrane oxygenation (1.0% versus 0.1%, p = 0.02), and the intensive care unit stay (mean 3.6 versus 2.6 days, p < 0.001) and inhospital stay (mean 11.3 versus 10.0 days, p < 0.001) were significantly longer compared with the SIMA grafting cohort. Test for interaction showed that urgent operation in patients undergoing BIMA grafting was associated with higher risk of inhospital death (5.6% versus 1.3%, p = 0.009).Conclusions. Bilateral internal mammary artery grafting in elderly patients seems to be associated with a worse early outcome compared with SIMA grafting, particularly in patients undergoing urgent operation. Until more conclusive results are gathered, BIMA grafting should be reserved only for elderly patients with stable coronary artery disease, without significant baseline comorbidities and with long life expectancy. (C) 2018 by The Society of Thoracic Surgeons

Minimally invasive mitral valve surgery is generally performed through a right minithoracotomy, in contrast to the traditional full median sternotomy approach. Minimally invasive mitral valve surgery is performed with increasing frequency, and by reducing surgical trauma, several observational studies suggest potential benefits with decreased bleeding and postoperative pain, reduced incidence of sternal wound infections, reduced length of hospital stay and shortened recovery period after surgery. In this review, we present an overview of mitral valve surgery, summarize the available evidence regarding the minimally invasive approach and report our experiences from introducing a minimally invasive mitral valve surgery programme at the Karolinska University Hospital in Stockholm, Sweden.

Background Arterial air embolism during open heart surgery may cause postoperative complications including cerebral injury, myocardial dysfunction, and dysrhythmias. Despite standard de-airing techniques during surgery large amounts of arterial air emboli may still occur, especially during weaning from cardiopulmonary bypass. To prevent this insufflation of carbon dioxide in the wound cavity has been used since the 1950s. The aim of this study was to assess a new mini-diffuser for efficient carbon dioxide de-airing of a minimal invasive cardiothoracic wound cavity model. Up until now no device has been evaluated for this purpose. Methods A new insufflation device, a mini-diffuser, was tested. A thin plastic tube was used as control. The end of the mini-diffuser or the control, respectively, was positioned in a minimal invasive thoracic wound model. Remaining air content was measured during steady state and during intermittent suction with a rough suction device at different carbon dioxide flow rates. Measurements were also carried out in the open surgical wound during minimal invasive aortic surgery in six patients. Results The air content was below 1% 4 cm below the surface of the open wound model during continuous carbon dioxide inflow of 2–10 L/min with the mini diffuser. In comparison, carbon dioxide insufflation via the open-ended tube resulted in a mean air content between 10 and 75%. The mean air content of the wound model remained below 1% at a carbon dioxide flow rate of 3–5 L/min during intermittent application of a suction device with a suction rate of 15 L/min. In 6 patients undergoing minimal invasive aortic valve replacement air content in the open surgical wound remained below 1% at a continuous carbon dioxide flow rate of 5 and 8 L/min via the mini-diffuser, respectively. Conclusions The mini diffuser was effective for carbon dioxide de-airing, i.e.

Salvage coronary artery bypass grafting (CABG) is often performed for cardiogenic shock on compassionate basis without clinical data justifying this aggressive approach. The aim of this study was to analyze early and intermediate outcomes after salvage CABG. We retrospectively reviewed the data of 85 patients who underwent salvage CABG at 11 European cardiac surgery centers. Salvage CABG was defined according to the EuroSCORE criteria, that is, a procedure performed in patients requiring cardiopulmonary resuscitation (external cardiac massage) en route to the operating theater or before induction of anesthesia. A percutaneous coronary intervention procedure preceded salvage CABG in 55 patients (64.7%). Thirty patients (35.3%) died during the inhospital stay. The mean EuroSCORE II was 32.0% and the observed-to-expected ratio was 1.08. Salvage CABG was associated with high rates of postoperative stroke (9.4%), resternotomy for bleeding (23.5%), resternotomy for hemodynamic instability (15.3%), dialysis (18.8%), severe gastrointestinal complications (12.9%), and deep sternal wound infection (10.6%). Survival at 1, 3, and 5 years was 58.6%, 49.8%, and 40.9%, respectively. Twenty patients (23.5%) were postoperatively treated with extracorporeal membrane oxygenation (ECMO). The rates of adverse events after ECMO were particularly high (stroke 40%, resternotomy for bleeding 60%, dialysis 35%, gastrointestinal complications 30%, and deep sternal wound infection 30%). Of patients treated with ECMO, 8 (40%) survived to discharge, and 1-year survival was 29.2%. Salvage CABG is associated with high risk of immediate mortality and severe adverse events. However, the observed immediate and intermediate outcome justify coronary surgery in these critically ill patients. A number of these patients are currently treated by ECMO, and its results are encouraging.

Minimally invasive mitral valve surgery Conventional mitral valve surgery is performed through a full median sternotomy. Minimal invasive mitral valve surgery was introduced in the mid 1990s and is performed through a right mini-thoracotomy. Minimal access mitral valve surgery has grown in popularity and by reducing surgical trauma potential benefits include decreased postoperative bleeding and pain, reduced incidence of sternal wound infections and shortened recovery period after surgery. We report our experience in 97 patients operated during one year where mitral valve surgery was performed through a minimally invasive technique.

Background: The prognostic impact of cross-clamp time (XCT) in patients undergoing isolated coronary artery bypass grafting (CABG) has not been thoroughly investigated. Material and Methods: 2957 patients who underwent on-pump isolated CABG from the prospective multicentre E-CABG study were the subjects of this analysis. Results: The mean XCT in this series was 58 ± 25 minutes Cross-clamp time was >60 minutes in 1134 patients (38.3%), >75 minutes in 619 patients (20.9%) and >90 minutes in 296 patients (10.0%). Multivariate analysis showed that XCT was an independent predictor of 30-day mortality (p < 0.0001, OR 1.027, 95%CI 1.015–1.039) along with age (p < 0.0001), female gender (p = 0.001), pulmonary disease (p = 0.001), poor mobility (p = 0.002), urgency status (p = 0.007), critical preoperative status (p = 0.002) and participating centres (p = 0.015). Adjusted risk of 30-day mortality was highest for XCT >75 minutes (2.9% vs. 1.7%, p = 0.002, OR 3.479, 95%CI 1.609–7.520). Analysis of 428 propensity score matched pairs showed that XCT >75 minutes was associated with significantly increased risk of early mortality, prolonged use of inotropes, postoperative use of intra-aortic balloon pump, use of extracorporeal membrane oxygenation, atrial fibrillation, prolonged stay in the intensive care unit and of composite major adverse events. Conclusions: Isolated CABG is currently performed with prolonged XCT in a significant number of patients and this seems to be a determinant of poor early outcome.

Background The aim of this study was to analyze early postoperative outcomes and 2-year survival after aortic valve replacement (AVR) with the sutureless Perceval bioprosthesis (Sorin Biomedica Cardio Srl, Salluggia, Italy) performed through ministernotomy compared with full sternotomy. Methods This was a study of 267 consecutive patients who underwent isolated AVR with the sutureless Perceval bioprosthesis between 2007 and 2014 at 6 European centers. Of these, 189 (70.8%) were performed through ministernotomy and 78 through a full sternotomy. Propensity score matching was used to reduce selection bias. Results In the overall cohort of ministernotomy and full sternotomy patients, in-hospital mortality was 1.1% and 2.6% and 2-year survival was 92% and 91%, respectively. Propensity score matching resulted in 56 pairs with similar characteristics and operative risk. Aortic cross-clamp (44 minutes in both groups, p = 0.931) and cardiopulmonary bypass time (69 vs 74 minutes, p = 0.363) did not differ between the groups. Apart from higher values in the ministernotomy group for postoperative peak gradients (28.1 vs 23.3 mm Hg, p = 0.026) and mean aortic valve gradients (15.2 vs 11.7 mm Hg, p = 0.011), early postoperative outcomes did not differ in the propensity-matched cohort. There were no differences in the in-hospital mortality rate or 2-year survival between the groups. Conclusions AVR with the sutureless Perceval bioprosthesis through a ministernotomy was a safe and reproducible procedure that was not associated with prolonged aortic cross-clamp or cardiopulmonary bypass time compared with a full sternotomy. Early postoperative outcomes and 2-year survival were comparable between patients undergoing ministernotomy and full sternotomy.

Background— The clinical impact of prior percutaneous coronary intervention (PCI) in patients requiring coronary artery bypass grafting (CABG) remains unsettled. We sought to determine whether prior PCI is associated with adverse outcome after CABG. Methods and Results— Data from the prospective E-CABG (European Multicenter Study on Coronary Artery Bypass Grafting) conducted between January 2015 and March 2016 at 16 European centres were analyzed using propensity weighted methodology to adjust for confounding. A parallel systematic review/meta-analysis (MEDLINE, Embase, SCOPUS, and Cochrane Library) through September 2017 was accomplished. Of a total of 3641 adult patients included in the E-CABG study, 685 (19%) patients had a history of PCI. At multivariable level, prior PCI was not associated with an increased hospital mortality in both unweighted and weighted patient groups (odds ratio, 0.73; 95% confidence interval, 0.29–1.38; P =0.33 and odds ratio, 0.90; 95% confidence interval, 0.39–2.08; P =0.81, respectively). Subgroup analyses confirmed that prior PCI had no impact on hospital mortality and morbidity, including reexploration for bleeding, blood transfusion, hospital resource use, and neurological, renal, and cardiac complications. The systematic review provided a total of 71 366 individuals and showed a trend toward higher in-hospital/30-day mortality (adjusted odds ratio, 1.30; 95% confidence interval, 0.99–1.70; I 2 =43.1%) in patients with prior PCI. Conclusions— Our prospective multicenter study showed that prior PCI was not associated with an increased risk of mortality or other adverse outcomes in patients undergoing CABG. In light of a trend toward increased mortality observed in the meta-analysis, further studies are needed to ascertain the prognostic impact of prior PCI in the outcome after CABG. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT02319083.

Background The prevalence of hypo‐attenuated leaflet thickening ( HALT ) and reduced leaflet motion ( RLM ) is unknown in surgically implanted bioprostheses because systematic investigation of HALT and/or RLM is limited to a few catheter‐based valves. The aim of this study was to investigate the prevalence of HALT and RLM by cardiac computed tomography in patients who underwent surgical aortic valve replacement and received a Perceval sutureless aortic valve bioprosthesis. Methods and Results This was a single‐center prospective observational study that included 47 patients (83.5% of the total number of implantations) who underwent surgical aortic valve replacement with implantation of the Perceval sutureless bioprosthesis (LivaNova PLC, London, UK) at Karolinska University Hospital in Stockholm, Sweden from 2012 to 2016 and were studied by cardiac computed tomography. Cardiac computed tomography was performed at a median of 491 days (range 36–1247 days) postoperatively. HALT was found in 18 (38%) patients and RLM in 13 (28%) patients. All patients with RLM had HALT . Among patients with HALT , 5 out of 18 patients (28%) were treated with anticoagulation (warfarin or any novel oral anticoagulant) at the time of cardiac computed tomography. Among patients with RLM , 3 out of 13 patients (23%) were treated with anticoagulation. Conclusions HALT and RLM were prevalent in the surgically implanted Perceval sutureless aortic valve bioprosthesis. Both HALT and RLM were found in patients with ongoing anticoagulation treatment. Whether these findings are associated with adverse events needs further study. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02671474.

OBJECTIVES Right ventricular (RV) function is impaired after cardiac surgery, possibly because of the opening of the pericardium. In minimally invasive aortic valve replacement, the pericardium is only partially incised. METHODS A randomized trial compared RV function after ministernotomy versus full sternotomy in 40 adults undergoing aortic valve replacement at the Karolinska University Hospital. Primary outcomes were tricuspid annular plane systolic excursion, RV pulsed-wave tissue Doppler velocity, RV fractional area change and basal and mid-RV transversal diameters on postoperative Days 4 and 40. RESULTS On postoperative Day 4, the tricuspid annular plane systolic excursion had decreased in both groups [ministernotomy: median (Q1-Q3) 25 (21-28) vs 16 (11-18), P

Objective The aim of this study was to evaluate the outcome of aortic valve replacement with the sutureless Perceval S aortic valve bioprosthesis (Sorin Biomedica Cardio Srl, Saluggia, Italy). Methods This is a retrospective analysis of 314 patients (mean age, 77.9 ± 5.0 years, mean European System for Cardiac Operative Risk Evaluation II, 9.0% ± 7.6%) who underwent aortic valve replacement with the Perceval S valve with (94 patients) or without (220 patients) concomitant coronary artery bypass surgery at 5 European centers. Results The Perceval S valve was successfully implanted in all but 1 patient (99.7%). The mean aortic crossclamping time was 43 ± 20 minutes (isolated procedure, 39 ± 15 minutes; concomitant coronary surgery, 52 ± 26 minutes). Severe paravalvular leak occurred in 2 patients (0.6%). In-hospital mortality was 3.2% (1.4% after isolated procedure and 7.4% after concomitant coronary surgery). In-hospital mortality was 2.8% and 4.0% among patients with a European System for Cardiac Operative Risk Evaluation II less than 10% and 10% or greater, respectively ( P = .558). Octogenarians had slightly higher in-hospital mortality (5.2% vs 2.0%, P = .125; after isolated procedure: 2.7% vs 0.7%, P = .223; after concomitant coronary surgery: 9.5% vs 5.8%, P = .491) compared with younger patients. Full sternotomy did not increase the in-hospital mortality risk compared with ministernotomy or minithoracotomy access (1.3% vs 1.4%, when adjusted for baseline covariates: P = .921; odds ratio, 0.886; 95% confidence interval, 0.064-12.346). One-year survival was 90.5%. Freedom from valve-related mortality, stroke, endocarditis, and reoperation was 99.0%, 98.1%, 99.2%, and 98.3%, respectively. Conclusions The sutureless Perceval S valve is associated with excellent early survival in high-risk patients, particularly among those undergoing an isolated procedure. Further studies are needed to prove the durability of this bioprosthesis.

Background: The evidence of the benefits of using venoarterial extracorporeal membrane oxygenation (VA-ECMO) after coronary artery bypass grafting (CABG) is scarce. Methods: We analyzed the outcomes of patients who received VA-ECMO therapy due to cardiac or respiratory failure after isolated CABG in 12 centers between 2005 and 2016. Patients treated preoperatively with ECMO were excluded from this study. Results: VA-ECMO was employed in 148 patients after CABG for median of 5.0 days (mean, 6.4, SD 5.6 days). Inhospital mortality was 64.2%. Pooled in-hospital mortality was 65.9% without significant heterogeneity between the centers (I-2 8.6%). The proportion of VA-ECMO in each center did not affect in-hospital mortality (p = 0.861). No patients underwent heart transplantation and six patients received a left ventricular assist device. Logistic regression showed that creatinine clearance (p = 0.004, OR 0.98, 95% CI 0.97-0.99), pulmonary disease (p = 0.018, OR 4.42, 95% CI 1.29-15.15) and pre-VA-ECMO blood lactate (p = 0.015, OR 1.10, 95% CI 1.02-1.18) were independent baseline predictors of in-hospital mortality. One-, 2-, and 3-year survival was 31.0%, 27.9%, and 26.1%, respectively. Conclusions: One third of patients with need for VA-ECMO after CABG survive to discharge. In view of the burden of resources associated with VA-ECMO treatment and the limited number of patients surviving to discharge, further studies are needed to identify patients who may benefit the most from this treatment. (C) 2017 Elsevier B.V. All rights reserved.

BACKGROUND Excessive bleeding and blood transfusion are associated with adverse outcome after cardiac surgery, but their mechanistic effects are difficult to disentangle in patients with increased operative risk. This study aimed to evaluate the incidence and prognostic impact of bleeding and transfusion of blood products in low-risk patients undergoing coronary artery bypass grafting (CABG). STUDY DESIGN AND METHODS Sixteen tertiary European centers of cardiac surgery contributed to the prospective European registry of CABG (E-CABG). The severity of bleeding was defined by the E-CABG bleeding severity classification and universal definition of perioperative bleeding (UDPB) classification. RESULTS Of 1213 patients with EuroSCORE II of less than 2% (mean, 1.1 ± 0.4%), 18.5% suffered from mild bleeding (E-CABG bleeding Grade 1) and 3.4% experienced severe bleeding (E-CABG bleeding Grade 2-3). Similarly, 19.7% had UDPB Class 2 and 5.9% had UDPB Classes 3 and 4. Mild and severe bleeding defined by the E-CABG and UDPB classifications were associated with an increased risk of several adverse events as adjusted by multiple covariates. The risk of death, stroke, and acute kidney injury was particularly increased in patients with severe bleeding. CONCLUSION Severe bleeding is rather uncommon in low-risk patients undergoing CABG, but it is associated with an increased risk of major adverse events. Prevention of excessive perioperative bleeding and patient blood management may improve the outcome of cardiac surgery also in low-risk patients.

Glycated hemoglobin (HbA1c) is a suspected risk factor for sternal wound infection (SWI) after CABG.Methods and Results:Data on preoperative HbA1c and SWI were available in 2,130 patients undergoing isolated CABG from the prospective E-CABG registry. SWI occurred in 114 (5.4%). Baseline HbA1c was significantly higher in patients with SWI (mean, 54±17 vs. 45±13 mmol/mol, P0.0001). This difference was also observed in patients without a diagnosis of diabetes (P=0.027), in insulin-dependent diabetic (P=0.023) and non-insulin-dependent diabetic patients (P=0.034). In the overall series, HbA1c70 mmol/mol (NGSP units, 8.6%) was associated with the highest risk of SWI (20.6% vs. 4.6%; adjusted OR, 5.01; 95% CI: 2.47-10.15). When dichotomized according to the cut-off 53 mmol/mol (NGSP units, 7.0%) as suggested both for diagnosis and optimal glycemic control of diabetes, HbA1c was associated with increased risk of SWI in the overall series (10.6% vs. 3.9%; adjusted OR, 2.09; 95% CI: 1.24-3.52), in diabetic patients (11.7% vs. 5.1%; adjusted OR, 2.69; 95% CI: 1.38-5.25), in patients undergoing elective surgery (9.9% vs. 2.7%; adjusted OR, 2.09; 95% CI: 1.24-3.52) and in patients with bilateral mammary artery grafts (13.7% vs. 4.8%; adjusted OR, 2.35; 95% CI: 1.17-4.69).Screening for HbA1c before CABG may identify untreated diabetic patients, as well as diabetic patients with suboptimal glycemic control, at high risk of SWI.

International audience; INTRODUCTION: This study was planned to investigate the impact of severe bleeding and blood transfusion on the development of stroke after coronary surgery.METHODS: This cohort study includes 2357 patients undergoing isolated CABG from the prospective European Coronary Artery Bypass Grafting (E-CABG) registry. Severity of bleeding was categorized according to the Universal Definition of Perioperative Bleeding (UDPB), E-CABG and PLATO definitions.RESULTS: Thirty patients (1.3%) suffered postoperative stroke. The amount of transfused red blood cell (RBC) (OR 1.10, 95%CI 1.03-1.18), preoperative use of unfractioned heparin (OR 4.49, 95%CI 1.91-10.60), emergency operation (OR 3.97, 95%CI 1.47-10.74), diseased ascending aorta (OR 4.62, 95%CI 1.37-15.65) and use of cardiopulmonary bypass (p = 0.043, OR 4.85, 95%CI 1.05-22.36) were independent predictors of postoperative stroke. Adjusted analysis showed that UDPB classes 3-4 (crude rate: 3.6% vs. 1.0%; adjusted OR 2.66, 95%CI 1.05-6.73), E-CABG bleeding grades 2-3 (crudes rate: 6.3% vs. 0.9%; adjusted OR 5.91, 95%CI 2.43-14.36), and PLATO life-threatening bleeding (crude rate: 2.5% vs. 0.6%, adjusted OR 3.70, 95%CI 1.59-8.64) were associated with an increased risk of stroke compared with no or moderate bleeding.CONCLUSIONS: Bleeding and blood transfusion are associated with an increased risk of stroke after CABG, which is highest in patients with severe bleeding.

Background— Endothelial dysfunction plays an important role in the early development of atherosclerosis and vascular complications in type 2 diabetes mellitus. Increased expression and activity of arginase, metabolizing the nitric oxide substrate l -arginine, may result in reduced production of nitric oxide and thereby endothelial dysfunction. We hypothesized that inhibition of arginase activity improves endothelial function in patients with coronary artery disease (CAD) and type 2 diabetes mellitus. Methods and Results— Three groups of subjects were included: 16 patients with CAD, 16 patients with CAD and type 2 diabetes mellitus (CAD+Diabetes), and 16 age-matched healthy control subjects. Forearm endothelium-dependent and endothelium-independent vasodilatation were assessed with venous occlusion plethysmography before and during intra-arterial infusion of the arginase inhibitor N ω -hydroxy-nor- l -arginine (nor-NOHA; 0.1 mg/min). Nor-NOHA was also coinfused with the nitric oxide synthase inhibitor ( N G -monomethyl L-arginine). The expression of arginase was determined in the internal mammary artery of patients undergoing bypass surgery. Nor-NOHA markedly increased endothelium-dependent vasodilatation (up to 2-fold) in patients with CAD+Diabetes and CAD ( P N G -monomethyl L-arginine completely inhibited the increase in endothelium-dependent vasodilatation induced by nor-NOHA. Endothelium-independent vasodilatation was slightly improved by nor-NOHA in the CAD+Diabetes group. Arginase I was expressed in vascular smooth muscle cells and endothelial cells, and arginase II was expressed in endothelial cells of patients with and without diabetes mellitus. Conclusions— Arginase inhibition markedly improves endothelial function in patients with CAD and type 2 diabetes mellitus suggesting that increased arginase activity is a key factor in the development of endothelial dysfunction.

BACKGROUND:The open surgical wound is exposed to cold and dry ambient air resulting in heat loss through radiation, evaporation, and convection. Also, general and neuraxial anesthesia decrease the patient’s core temperature. Despite routine preventive measures mild intraoperative hypothermia is stil

Background The open surgical wound is exposed to cold dry ambient air, resulting in substantial heat loss through radiation, evaporation, and convection. At the same time, anesthesia decreases the patient’s core temperature. Despite preventive measures, mild intraoperative hypothermia has been associated with postoperative morbidity. We hypothesized that local insufflation of warmed humidified carbon dioxide (CO2) would maintain wound and core temperature.

ObjectiveMinimally invasive aortic valve replacementsurgery (MIAVR) is an alternative surgical technique to conventional aortic valve replacement surgery (AVR) in selected patients. The randomised study Cardiac Function after Minimally Invasive Aortic Valve Implantation (CMILE) showed that right ventricular (RV) longitudinal function was reduced after both MIAVR and AVR, but the reduction was more pronounced following AVR. However, postoperative global RV function was equally impaired in both groups. The purpose of this study was to explore alterations in RV mechanics and contractility following MIAVR as compared with AVR.MethodsA predefined post hoc analysis of CMILE consisting of 40 patients with severe aortic valve stenosis who were eligible for isolated surgical aortic valve replacement were randomised to MIAVR or AVR. RV function was assessed by echocardiography prior to surgery and 40 days post-surgery.ResultsComparing preoperative to postoperative values, RV longitudinal strain rate was preserved following MIAVR (−1.5±0.5 vs −1.5±0.4 1/s, p=0.84) but declined following AVR (−1.7±0.3 vs −1.4±0.3 1/s, pConclusionsRV contractility was preserved following MIAVR but was deteriorated following AVR. RV longitudinal function reduced substantially following AVR. A decline in RV longitudinal function was also observed following MIAVR, however, to a much lesser extent.

In open surgery, heat is lost due to radiation and evaporation through the wound. Hypothermia causes tissue hypoxia and impairs various cellular immune functions that increases the risk for postoperative wound infections and delayed wound healing. The patient's body is usually well protected with heating arrangements, but the open wound is left unprotected and until now no practical method has been available to protect it thermically. We therefore investigated if insufflation of an open surgical wound with carbon dioxide would affect wound temperature. In 10 patients undergoing cardiac surgery, the sternotomy wound was insufflated with dry, room temperature carbon dioxide via a gas diffuser for 2 minutes. A heat-sensitive camera measured the wound temperature before, during, and after insufflation. Exposure to carbon dioxide increased the median temperature of the whole wound by 0.5 degrees C (p=0.01). The temperature of the area distant to the diffuser increased by 1.2 degrees C (p

Aprotinin reduces bleeding and transfusion rates in patients undergoing coronary surgery while on clopidogrel. However, safety studies have indicated that aprotinin may have a possible adverse effect related to an increased incidence of thromboembolic events. We therefore studied the adenosinediphosphate (ADP) mediated platelet aggregation before and after administration of aprotinin in patients on clopidogrel. Fifteen clopidogrel-treated patients with acute coronary syndrome undergoing coronary surgery were studied. ADP-mediated platelet aggregation and platelet count ratio (%) were measured before and after a bolus dose [2 x 10(6) kallikrein inhibiting units (KIU)] of aprotinin. Aprotinin induced an increased aggregation in 11 of 15 patients (73%), and a decrease was registered in two patients (13%). The median (25th/75th percentile) ADP-mediated platelet aggregation before and after aprotinin was 84% (76/91) and 94% (86/97, P0.01). Clopidogrel non-responders with90% aggregation (n=4) had a median aggregation of 94.5% (91.5/97.5) vs. 82% (73/87, P0.01) in the responders (n=11). The median increase in platelet aggregation after aprotinin was 8% (5/20) in the responders vs. 0% (-5.25/3, P0.01) in the non-responders. Aprotinin increased ADP induced platelet aggregation from 84 to 94% in patients on clopidogrel, which corresponds to a median decrease in relative platelet inhibition of50%.

OBJECTIVE Patients with acute coronary syndrome have an increased risk of cardiac death or myocardial infarction after urgent coronary artery bypass surgery (CABG). Symptoms and signs of ongoing ischemia, such as elevated cardiac troponin T and angina at rest at the time of the operation identify patients at particular risk of early death, but the impact of these parameters on long-term survival is poorly investigated. METHODS Two hundred patients, 100 with acute coronary syndrome and 100 with stable angina pectoris, underwent primary isolated CABG. Troponin T levels were assayed immediately before the operation and at 64 hours after the aortic cross-clamp had been removed. The severity of the patients' unstable symptoms was classified according to Braunwald. Early outcome and long-term survival were analyzed. RESULTS Among the unstable patients 3 deaths occurred within 30 days of the operation, and there were 12 late deaths. In the control group there were no early and 19 late deaths. The patients were followed up for 6.5 years (0-7.7 years), a total of 1 294 patient years. The cumulative long-term survival was 85 % for the unstable and 81 % for the stable patients ( P = 0.75). Freedom from cardiac death was 92 % in unstable and 94 % in stable patients. Five unstable and one of the stable patients suffered postoperative myocardial infarction ( P = 0.01). A troponin T level > 0.1 microg/L immediately prior to the operation was associated with an increased need for postoperative pharmacological inotropic support ( P < 0.001) and intra-aortic balloon counterpulsation ( P = 0.004). Symptoms and signs of ongoing ischemia (angina at rest and elevated troponin T immediately prior to the operation) had no predictive value for long-term survival. CONCLUSION In patients with acute coronary syndrome, parameters such as elevated troponin T and angina at rest herald an increased risk of postoperative myocardial infarction and indicate the need for pharmacological and mechanical inotropic support but have no bearing on long-term survival.

The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial. Importance: The optimal timing of discontinuation of ticagrelor before cardiac surgery is controversial.Objective: To evaluate the safety of preoperative use of ticagrelor with or without aspirin in patients with acute coronary syndromes (ACS) undergoing isolated coronary artery bypass grafting (CABG) compared with aspirin alone.Design, Setting, and Participants: This prospective, multicenter clinical trial was performed at 15 European centers of cardiac surgery. Participants were patients with ACS undergoing isolated CABG from the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) registry between January and September 2015.Exposures: Before surgery, patients received ticagrelor with or without aspirin or aspirin alone.Main Outcomes and Measures: Severe bleeding as defined by the Universal Definition of Perioperative Bleeding (UDPB) and E-CABG bleeding classification criteria. A propensity score-matched analysis was performed to adjust for differences in baseline and operative covariates.Results: Of 2482 patients from the E-CABG registry, the study cohort included 786 (31.7%) consecutive patients with ACS (mean [SD] age, 67.1 [9.3] years; range, 32-88 years), and 132 (16.8%) were female. One-to-one propensity score matching provided 215 pairs, whose baseline and operative covariates had a standardized difference of less than 10%. Preoperative use of ticagrelor was associated with a similar risk of bleeding according to the UDPB and E-CABG bleeding classifications, but the incidence of platelet transfusion was higher in the ticagrelor group (13.5% [29 of 215] vs 6.0% [13 of 215]). Compared with those receiving aspirin alone, continuing ticagrelor up to the time of surgery or discontinuing its use less than 2 days before surgery was associated with a higher risk of platelet transfusion (22.7% [5 of 22] vs 6.4% [12 of 187]) and E-CABG bleeding grades 2 and 3 (18.2% [4 of 22] vs 5.9% [11 of 187]) and tended to have an increased risk of UDPB grades 3 and 4 (22.7% [5 of 22] vs 9.6% [18 of 187]). Among patients in whom antiplatelet drug use was discontinued at least 2 days before surgery, the incidence of platelet transfusion was 12.4% (24 of 193) in the ticagrelor group and 3.6% (1 of 28) in the aspirin-alone group.Conclusions and Relevance: In propensity score-matched analyses among patients with ACS undergoing CABG, the use of preoperative ticagrelor with or without aspirin compared with aspirin alone was associated with more platelet transfusion but similar degree of bleeding; in patients receiving ticagrelor 1 day before or up until surgery, there was an increased rate of severe bleeding.

A 56-year-old woman visited her general practitioner 12 months prior with eczema. Blood samples showed anaemia, a haemoglobin level of 105 g/L and a high erythrocyte sedimentation rate (ESR) of 80 mm. Her eczema was diagnosed as discoid lupus erythaematosus but there were no signs of systemic lupus erythaematosus. Extensive investigations were made including testing of serial blood samples, repeated examinations by specialists in dermatology, rheumatology and gynaecology, and several X-rays including CT of the chest and the abdomen, all without finding a reasonable underlying diagnosis. One year later, the patient presented with dyspnoea associated with effort and body position; she was sent for echocardiography, which showed an atrial myxoma filling almost the whole left atrium and affecting the mitral valve. She was treated with urgent surgical removal and now, 6 weeks postsurgery, has fully recovered. She no longer has dyspnoea, her haemoglobin level and ESR have normalised, and the eczema has almost disappeared.

Insufflation of carbon dioxide into the chest wound is used in open-heart surgery to de-air the heart and great vessels. In a cardiothoracic wound model, we compared the degree of air displacement achieved by a new insufflation device, a gas-diffuser, with that of a thin open-ended tube during steady-state and with carbon dioxide flows of 2.5, 5, 7.5, and 10 L/min. We also studied air displacement at the start of and after discontinuation of carbon dioxide insufflation with the gas-diffuser and evaluated the influence of an open pleura. During steady state, the gas-diffuser produced efficient air displacement in the wound cavity model at carbon dioxide flows ofor = 5 L/min (or = 0.65% remaining air), whereas the open-ended tube was inefficient (or = 82% remaining air) at all studied carbon dioxide flows (P0.001). An open pleural cavity prolonged the time needed to obtain a high degree of air displacement in the wound cavity (P = 0.001). Carbon dioxide insufflation of the cardiothoracic wound cavity should be initiated at a carbon dioxide flow of 10 L/min at least 1 min before the incision of the heart and great vessels and should be continued at a carbon dioxide flow of at least 5 L/min until surgical closure.

Objective: The authors aimed to validate the European Multicenter Study on Coronary Artery Bypass Grafting (E-CABG) classification of postoperative Complications in patients undergoing coronary artery bypass grafting (CABG).Design: Retrospective, observational study.Setting: University hospital.Participants: A total of 2,764 patients with severe coronary artery disease. Complete baseline, operative, and postoperative data were available for patients who underwent isolated CABG.Interventions: Isolated CABG.Measurements and Main Results: The E-CABG complication classification was used to stratify the severity and prognostic impact of adverse postoperative events. Primary outcome endpoints were 30-day, 90-day, and long-term all cause mortality. The secondary outcome endpoints was the length of intensive care unit stay. Both the E-CABG complication grades and additive score were predictive of 30-day (area under the receiver operating characteristics curve 0.866, 95% confidence interval [CI] 0.829-0.903; and 0.876; 95% CI 0.844-0.908, respectively) and 90-day (area under the receiver operating characteristics curve 0.850, 95% CI 0.812-0.887; and 0.863, 95% CI 0.829-0.897, respectively) all-cause mortality. The complication grades were independent predictors of increased mortality at actuarial (log-rank: p < 0.0001) and adjusted analysis (p < 0.0001; grade 1: hazard ratio [HR] 1.757, 95% CI 1.111-2.778; grade 2: HR 2.704, 95% CI 1.664-4.394; grade 3: HR 5.081, 95% CI 3.148-8.201). When patients who died within 30 days were excluded from the analysis, this grading method still was associated with late mortality (p < 0.0001). The grading method (p < 0.0001) and the additive score (rho, 0.514; p < 0.0001) were predictive of the length of intensive care unit stay.Conclusions: The E-CABG postoperative complication classification seems to be a promising tool for stratifying the severity and prognostic impact of postoperative complications in patients undergoing cardiac surgery. (C) 2016 Elsevier Inc. All rights reserved.

International audience; BACKGROUND: Clinical evidence in coronary surgery is usually derived from retrospective, single institutional series. This may introduce significant biases in the analysis of critical issues in the treatment of these patients. In order to avoid such methodological limitations, we planned a European multicenter, prospective study on coronary artery bypass grafting, the E-CABG registry. DESIGN: The E-CABG registry is a multicenter study and its data are prospectively collected from 13 centers of cardiac surgery in university and community hospitals located in six European countries (England, Italy, Finland, France, Germany, Sweden). Data on major and minor immediate postoperative adverse events will be collected. Data on late all-cause mortality, stroke, myocardial infarction and repeat revascularization will be collected during a 10-year follow-up period. These investigators provided a score from 0 to 10 for any major postoperative adverse events and their rounded medians were used to stratify the severity of these complications in four grades. The sum of these scores for each complication/intervention occurring after coronary artery bypass grafting will be used as an additive score for further stratification of the prognostic importance of these events. DISCUSSION: The E-CABG registry is expected to provide valuable data for identification of risk factors and treatment strategies associated with suboptimal outcome. These information may improve the safety and durability of coronary artery bypass grafting. The proposed classification of postoperative complications may become a valuable research tool to stratify the impact of such complications on the outcome of these patients and evaluate the burden of resources needed for their treatment. CLINICAL TRIALS NUMBER: NCT02319083

The optimal dose of protamine needed to reverse the anticoagulant effect of heparin after cardiopulmonary bypass is still not known. In this retrospective cohort study, we investigated 3 different dose regimes in 300 patients undergoing coronary artery bypass grafting. Group A patients (n = 100) were given protamine in the ratio of 1.3 mg to 1 mg heparin, group B patients (n = 100) were given 0.75 mg protamine to 1 mg heparin, and group C patients (n = 100) were given protamine in fractionated doses of 1 mg + 0.15 mg + 0.15 mg to 1 mg heparin. The groups were comparable in all major clinical and operative variables. The heparin dose was almost identical in the groups. The rate of red cell transfusion was significantly higher in group B than in the other groups. A similar but nonsignificant trend was observed in the incidence of resternotomy for postoperative bleeding, mediastinal drainage, and postoperative hemoglobin loss. The study demonstrates that a single bolus dose of 1.3 mg protamine to 1 mg heparin is safe and efficient for neutralizing heparin after cardiopulmonary bypass.

OBJECTIVES: The aim of this study was to analyse early postoperative outcomes and 2-year survival after aortic valve replacement (AVR) through a ministernotomy with a sutureless bioprosthesis implantation compared with a full sternotomy with implantation of a stented bioprosthesis. METHODS: Patients who underwent primary isolated non-emergent AVR at six European centres were included in the study. Of these, 182 (32%) underwent a ministernotomy with a sutureless bioprosthesis (ministernotomy sutureless group) and 383 (68%) a full sternotomy with a stented bioprosthesis (full sternotomy stented group). Propensity score matching was used to reduce selection bias. RESULTS: In the overall cohort, 30-day mortality was 1.6 and 2.1%, and 2-year survival was 92 and 92% in the ministernotomy sutureless group and in the full sternotomy stented group, respectively. Propensity score matching resulted in 171 pairs with similar characteristics and operative risk. Aortic cross-clamp (40 vs 65 min, P < 0.001) and cardiopulmonary bypass time (69 vs 87 min, P < 0.001) were shorter in the ministernotomy sutureless group. Patients undergoing ministernotomy received less packed red blood cells but the risk for postoperative permanent pacemaker implantation was higher. There were no differences regarding 30-day mortality or 2-year survival between the two groups. CONCLUSIONS: AVR through a ministernotomy with implantation of a sutureless bioprosthesis was associated with shorter aortic cross-clamp and cardiopulmonary bypass time and less transfusion of packed red blood cells, but a higher risk for postoperative permanent pacemaker implantation compared with a full sternotomy with a stented bioprosthesis.

The aim of this study was to compare the immediate outcome of patients undergoing transcatheter (TAVI) versus surgical aortic valve replacement with the sutureless Perceval bioprosthesis (SU-AVR). This is a retrospective multicenter analysis of 773 patients who underwent either TAVI (394 patients, mean age, 80.8 ± 5.5 years, mean EuroSCORE II 5.6 ± 4.9 %) or SU-AVR (379 patients, 77.4 ± 5.4 years, mean EuroSCORE II 4.0 ± 3.9 %) with or without concomitant myocardial revascularization. Data on SU-AVRs were provided by six European institutions (Belgium, Finland, Germany, Italy and Sweden) and data on TAVIs were provided by a single institution (Catania, Italy). In-hospital mortality was 2.6 % after SU-AVR and 5.3 % after TAVI (p = 0.057). TAVI was associated with a significantly high rate of mild (44.0 vs. 2.1 %) and moderate-severe paravalvular regurgitation (14.1 vs. 0.3 %, p < 0.0001) as well as the need for permanent pacemaker implantation (17.3 vs. 9.8 %, p = 0.003) compared with SU-AVR. The analysis of patients within the 25th and 75th percentiles interval of EuroSCORE II, i.e., 2.1-5.8 %, confirmed the findings of the overall series. One-to-one propensity score-matched analysis resulted in 144 pairs with similar baseline characteristics and operative risk. Among these matched pairs, in-hospital mortality (6.9 vs. 1.4 %, p = 0.035) was significantly higher after TAVI. SU-AVR with the Perceval prosthesis in intermediate-risk patients is associated with excellent immediate survival and is a valid alternative to TAVI in these patients.

Extracorporeal and implantable mechanical circulatory support devices are increasingly used for refractory cardiogenic shock. We describe a patient with a continuous-flow left ventricular assist device (LVAD) who developed refractory ventricular fibrillation (VF) and deteriorating right ventricular function, requiring emergency implantation of venoarterial extracorporeal membrane oxygenation (ECMO), which supported the patient for 23 days of continuous VF until urgent transplantation. We illustrate challenges in managing parallel competing flows in the 2 circuits (Figure). Figure. Schematic illustration of parallel extracorporeal membrane oxygenation (ECMO) and left ventricular assist device (LVAD). The ECMO flow bypasses the lungs and LVAD. The LVAD flow consists of pulmonary venous return and aortic regurgitant flow (illustration AB Typofom). The patient is a 45-year-old man with dilated cardiomyopathy and a HeartMate II (Thoratec, Pleasanton, CA) as a bridge to …

Left ventricular assist device (LVAD) implantation is associated with the risk of early postoperative right heart dysfunction, which may require urgent institution of mechanical right ventricular support. This is conventionally achieved by cannulation of the femoral vein or right atrial appendage for the inflow and the pulmonary artery for the outflow. However, this requires resternotomy with increased risk of wound and device infection, as well as excessive bleeding. We describe the use of peripheral venoarterial extracorporeal membrane oxygenation as a short-term treatment of right heart failure after HeartWare LVAD implantation.

Background In 2009, we started to screen all patients on the heart transplant waiting list for the presence of blood group anti-A or anti-B antibodies. From our experience with ABO-incompatible kidney transplantation, we know that transplantation can safely be performed if the antibody level is reduced to a titer of immunoglobulin G (IgG) 1:8. Methods We decided to accept all patients with anti-A or anti-B antibody titer≤1:8 for ABO-incompatible heart transplantation without any special pre-treatment and patients with antibody titers of IgG 1:16 and 1:32, provided 1 apheresis session could be performed immediately before transplantation. Results We found 6 of 13 patients were suitable for this program, and 2 ABO incompatible patients underwent successful transplantation with a follow-up of 1 year. Conclusion In heart transplant candidates where there are problems obtaining a compatible heart and who are not suitable for ventricular assist device support, ABO-incompatible heart transplantations can be considered using our protocol, provided that the levels of anti-A or anti-B antibodies are low.

Background and Purpose— Microemboli observed during coronary angiography can cause silent ischemic cerebral lesions. The aim of this study was to investigate if the number of particulate cerebral microemboli during coronary angiography is influenced by access site used. Methods— Fifty-one patients with stable angina pectoris referred for coronary angiography were randomized to right radial or right femoral arterial access. The number of particulate microemboli passing the middle cerebral arteries was continuously registered with transcranial Doppler. Results— The median (minimum–maximum range) numbers of particulate emboli were significantly higher with radial 10 (1–120) than with femoral 6 (1–19) access. More particulate microemboli passed the right middle cerebral artery with the radial access. Conclusions— This study indicates that the radial access used for coronary angiography generates more particulate cerebral microemboli than the femoral access and thus may influence the occurrence of silent cerebral injuries.