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Venoarterial extracorporeal membrane oxygenation (VA-ECMO) serves as a conventional short-term mechanical circulatory assist to support heart and lung functions. The short-term ventricular assist devices (ST-VAD) can, on the contrary, offer only circulatory support. A combination of VAD and oxygenator (Oxy-VAD) could help overcome this potential disadvantage. This is a retrospective case note study of patients supported on ST-VAD which required adding an oxygenator for extra respiratory support. The oxygenator was introduced in the ST-VAD circuit, either on the left or the right side. Twenty-two patients with the etiology of refractory cardiogenic shock in decompensation were supported on Oxy-VAD between years 2009 and 2019 at tertiary care . All patients were classified into class-I INTERMACS with a mean SOFA Score of 14 ± 2.58. 86.4% of patients were already on mechanical support pre-ST-VAD implant, 80% on VA-ECMO. The BiVAD implant accounted for 63.6%, followed by LVAD and RVAD with 27.3% and 9.1%. Mean duration of the ST-VAD was 8.5 days. The oxygenator was introduced in 14 RVAD and 8 LVAD circuits. The oxygenator was successfully weaned in 54.5% while ST-VAD was explanted in 31.8%. Discharge to home survival was 22.7%. Oxy-VAD proves a viable, and probably, a better option to VA-ECMO in acute cardiorespiratory decompensation. It offers organ-specific tailor-made support to the right and/or left heart and/or lungs. While on Oxy-VAD support, each organ performance can be assessed independently, and the assistance of the specifically improved organ can be weaned off without discontinuing the support for the rest.

Reopening the chest in patients with left ventricular assist devices at the time of a heart transplant is challenging due to adhesions and the possibility of injury to vital structures. The sternal sparing bilateral thoracotomy approach utilized to implant a left ventricular assist device minimizes the chances of such injuries and offers a cosmetically better outcome. We demonstrate a procedure for implanting a left ventricular assist device in a 54-year-old man diagnosed with dilated cardiomyopathy who suffered rapid decompensation despite maximum medical therapy.

Bridge to heart transplantation using the Levitronix CentriMag short-term ventricular assist device

Purpose We wanted to evaluate if direct procurement of the heart is possible in combination with normothermic regional perfusion of abdominal organs in donors after circulatory death. Description A donation after circulatory death pathway was used for a 41-year-old woman after an irreversible brain injury. After meeting criteria for the organ donation, the heart was retrieved and re-animated on ex situ perfusion system, and abdominal organs were perfused with normothermic regional perfusion. Evaluation All the donated organs and their recipients had excellent short-term outcome. Conclusions We demonstrated a successful combination of direct procurement of the heart and normothermic regional perfusion of the abdominal organs.

Background: Idiopathic pulmonary artery hypertension (iPAH) is a relatively minor indication for lung transplantation (LTx) with comparatively poorer outcomes. Extracorporeal life support (ECLS) in various forms is increasingly being used in the management of this entity. However, the data and experience with this therapy remains limited. We evaluated the role of ECLS in the management of severe iPAH patients as a bridge to LTx as well as post LTx support. Methods: A retrospective analysis of iPAH patients that received LTx between January 2007 and May 2014 was performed. Early- and mid-term outcomes were analyzed for this patient cohort. Also, early and mid-term outcomes after LTx were compared to the control group of patients with other diagnoses using unadjusted analysis and 1:3 propensity score matching. Results: Of 321 LTx performed during the study period in our centre 15 patients had iPAH as a cause of end-stage lung disease. Four iPAH (27%) patients were bridged to LTx utilizing ECLS in the form of veno-arterial ECMO and extra-corporeal CO 2 removal device, whereas 9 patients (60%) required ECLS support for primary graft dysfunction (PGD) after surgery. Patients with iPAH required more frequently on-pump LTx, both pre and post LTx ECLS, and had significantly lower pO 2 /FiO 2 ratio at 24, 48 and 72 hours after LTx. Also iPAH patients had significantly longer ICU and hospital stay. Whereas the incidence of postoperative bronchiolitis obliterans syndrome (BOS) and rejection was comparable to the control group, overall cumulative survival with up to 6 years follow-up was significantly poorer in the iPAH group. After propensity score matching, the results in terms of postoperative outcomes remained as in the unadjusted analysis. Conclusions: ECLS is an essential tool in the armamentarium of any lung transplant program treating iPAH with a potential of bridge patients to transplantation and to overcome graft dysfunction after LTx. Despite utilization of ECLS in the management of iPAH, the outcomes in terms of primary graft failure and survival remain poor compared to patients with other diagnoses.

Left ventricular assist device (LVAD) is now a routine therapy for advanced heart failure. Minimally invasive approach via thoracotomy for LVAD implantation is getting popular due to its potential advantage over the conventional sternotomy approach in terms of reduced risk at re-operation due to sternal sparing. We compared the approaches (thoracotomy and sternotomy) to determine the superiority. Minimally invasive approach involved fitting of the LVAD inflow cannula into left ventricle apex via left anterior thoracotomy and anastomosis of outflow graft to ascending aorta via right anterior thoracotomy. In the sternotomy approach, both the procedures were performed via sternotomy. Outcomes in patients after LVAD implantation were compared depending on these approaches for the surgery. Two hundred and five continuous flow LVAD implantations performed between July 2006 and June 2015 at a single center were divided based on surgical approach, that is, sternotomy (n = 180) and thoracotomy (n = 25) groups. There was no significant difference between the groups in relation to patient demographics, preoperative hemodynamic parameters, laboratory markers, or risk factors. There was no significant difference between the groups in terms of postoperative hemodynamic parameters, laboratory markers, bleeding and requirement of blood products, intensive care unit, and hospital stay or complications of LVAD surgery. There were no significant differences in terms of long-term survival (Log-Rank P = 0.953), however, thoracotomy, compared to sternotomy approach, incurred significantly less requirement of temporary right ventricular assist (4 vs. 19.4%, P = 0.041). Minimally invasive bilateral thoracotomy approach for LVAD implantation in addition to benefits of sternal sparing avoids dilatation of right ventricle and reduces chances of right ventricular failure requiring temporary right ventricular assist.

Donation after circulatory death (DCD) has the potential to expand the lung donor pool. We aimed to assess whether DCD affected the need for perioperative extracorporeal membrane oxygenation (ECMO) and perioperative outcomes in lung transplantation (LTx) as compared to donation after brain death (DBD). All consecutive LTxs performed between April 2017 and March 2019 at our tertiary center were analyzed. Donor and recipient preoperative characteristics, utilization of ECMO, and perioperative clinical outcomes were compared between DCD and DBD LTx. Multivariate models (frequentist and Bayes) were fitted to evaluate an independent effect of DCD on the intra- and postoperative need for ECMO. Out of 105 enrolled patients, 25 (23.8%) were DCD LTx. Donors' and preoperative recipients' characteristics were comparable between the groups. Intraoperatively, mechanical circulatory support (MCS) was more common in DCD LTx (56.0% vs. 36.2%), but the adjusted difference was minor (RR = 1.16, 95% CI 0.64-2.12 ; P = 0.613). MCS duration, and first and second lung ischemia time were longer in the DCD group. Postoperatively, DCD recipients more commonly required ECMO (32.0% vs. 7.5%) and the difference remained considerable after adjustment for the pre- and intraoperative covariates: RR = 4.11 (95% CI 0.95-17.7), P = 0.058, Bayes RR = 4.15 (95% CrI 1.28-13.0). Sensitivity analyses (two DCD-DBD matching procedures) supported a higher risk of postoperative ECMO need in DCD patients. Incidence of delayed chest closure, postoperative chest drainage, and renal replacement therapy was higher in the DCD group. Early postoperative outcomes after DCD LTx appeared generally comparable to those after DBD LTx. DCD was associated with a higher need for postoperative ECMO which could influence clinical outcomes. However, as the DCD group had a significantly higher use of EVLP with more common ECMO preoperatively, this might have contributed to worse outcomes in the DCD group.

Background We investigated changes in estimated glomerular filtration rate (eGFR) after left ventricular assist device (LVAD) implant and the impact on long-term outcomes. Methods A retrospective analysis was conducted for 255 patients with LVADs, divided into 2 groups based on preimplant eGFR ( 60 mL/min/1.73 m2) and into 6 grades (grade 1, >90 mL/min/1.73 m2 normal; grade 2, 60-89 mild dysfunction; grade 3, 45-59 moderate; grade 4, 30-44 moderate to severe; grade 5, 15-29 severe; or grade 6, Results One-month postimplant eGFR of the total cohort increased from a baseline of 75.19 ± 34.35 to 118.97 ± 67.62 mL/min/1.73 m2 (P 60 followed the same pattern as the entire cohort. The preimplant eGFR 60 was 76%, 54%, and 48% and for eGFR Conclusions Patients with a low preimplant eGFR derive benefit from LVAD therapy, with eGFR remaining elevated above preimplant levels. Preimplant renal dysfunction did not impact negatively on long-term morbidity and mortality.

Lung transplantation remains the definite treatment for various end-stage lung diseases. Cold flush perfusion, the standard method for organ procurement has severe limitations. Organ Care System (OCS; TransMedics, Inc., Andover, USA) is an approved method to preserve hearts for transplantation that allows for greatly reduced cold ischemic time. Consequently, the use of an adapted OCS lung as a portable full ex-vivo lung perfusion system in lung transplantation is currently under close evaluation. Areas covered: The aim of this article is to review the advantages and the role of the OCS in the field of lung transplantation by reviewing the latest literature and evaluating this novel procurement technique in the context of conventional methods like cold flush and regular ex-vivo lung perfusion. Expert commentary: The use of OCS in the field of lung transplantation has great potential for improved patients outcomes and is justified in cases with (i) marginal donor lungs, (ii) foreseeable long time of transportation (iii) high-risk recipient or donor /recipient profiles, particularly in the setting of an overall increasing need for suitable donor organs. Results from two major multi-centre prospective studies are pending to objectively assess the possible advantages of this portable ex-vivo lung perfusion system.

Background Because of improved surgical expertise and intraoperative management, pleural disease (PD+) represents a relatively minor contraindication to lung transplantation (LTx). The presence of pleural abnormalities from previous procedures or pleural involvement from fungal or bacterial disease is not considered a limiting factor for LTx. However there are no studies available to assess the impact of pleural diseases on short- and midterm outcomes after LTx. Methods We retrospectively reviewed 163 consecutive patients who underwent LTx between 2010 and 2013. Patients were divided according to the presence of pleural abnormalities before the operation (PD+ versus PD–). The primary end point of the study was primary graft dysfunction (PGD; grade 3) and overall survival. To avoid possible selection bias and to heck the robustness of the results, a propensity score–matching analysis (1:3) was performed. Results A total of 26 patients (16%) had pleural abnormalities before transplantation. Intra- and postoperative variables were comparable. PD+ was associated with a significantly higher incidence of PGD at 0 and 48 hours postoperatively ( p = 0.037 and p = 0.032, respectively). Moreover, PD+ was associated with significantly worse survival at 3 months ( p = 0.021). Although there was a trend toward worse early overall survival in the Kaplan-Meier estimate (Breslow p = 0.050), midterm survival was comparable (log-rank p = 0.240). Conclusions LTx in patients with preoperative pleural abnormalities is feasible. Identifying higher-risk recipients with pleural abnormalities might have important clinical relevance because of a higher incidence of PGD and worse early survival, even though midterm survival is comparable.

Limited data are available about lung transplantation (LTx) from donors suffering cardiac arrest (CA) prior to actual donation.A retrospective analysis of LTx performed between January 2007 and September 2012 was done with the focus on CA in donors. The recipients were grouped depending on the history of donor CA and CA duration (downtime) as: No cardiac arrest ("NoCA"), CA downtime less than 20 min ("CA20"), and CA downtime equal to or more than 20 min ("CA20"). Early and mid-term outcomes after LTx were compared among the three groups.A total of 237 LTx were performed during the study period. One hundred eighty-eight patients received organs from "NoCA" donors, 25 from "CA20" donors, and 24 patients from "CA20" donors. There was a trend toward better overall cumulative survival in both CA groups (log rank p = 0.076) whereas the survival in the "CA20" group was significantly better than in the "NoCA" group in the subgroup analysis (log rank p = 0.045). Freedom from bronchiolitis obliterans syndrome (BOS) also increased with increase in CA duration, although it did not reach statistical significance.Transplantation of lungs from donors with a history of CA is safe and feasible. Longer duration of cardiac arrest may improve the outcomes after the LTx in terms of survival and freedom from BOS.

Extracorporeal membrane oxygenation (ECMO) as a bridge to lung transplant (LTx) is not uncommon, but it is not commonplace yet. We present a case of a 45-year-old man with cystic fibrosis with recent deterioration in lung function who was initially supported with veno-venous (VV) ECMO. However, he subsequently required conversion to veno-veno-arterial (VVA) ECMO. After 21 days of support, he underwent double lung transplantation, with an uneventful postoperative course. This case shows that, in patients with end-stage respiratory failure awaiting lung transplantation, extracorporeal life support may require escalation to improve gas exchange and address circulatory requirements.

Objectives: Increasing incidence of end-stage heart failure has moved the therapy with left ventricular assist devices to the forefront of surgical treatment. Moreover, continuous sophistication in this technology has resulted in increasing proportion of patients on prolonged support. Early and late complications after left ventricular assist device as a bridge to transplantation and present factors associated with long-term support and long-term outcomes of patients supported for at least 1 year were compared. Methods: A total of 163 consecutive patients who underwent left ventricular assist device implantation as bridge to transplantation were included. A total of 79 patients were supported for at least 1 year (long-term support), whereas 84 patients were supported for less than 1 year (short-term group). Results: Factors associated with a successful long-term support were male gender (p Conclusion: Prolonged left ventricular assist device support as bridge to transplantation is associated with lower mortality and lower incidence of device failure requiring device exchange. However, long-term support reduces the chance of device explantation for myocardial recovery and increases the incidence of higher-grade aortic regurgitation in the follow-up.

BACKGROUND Lung transplantation remains the gold standard treatment for patients with end-stage lung disease. Lobar lung transplantation allows for transplantation of size-mismatch donor lungs in small recipients; however, donor lung volume reduction represents a challenging surgical technique. In this paper we present our initial experience with bilateral lobectomy in donor lungs before lobar lung transplantation using normothermic perfusion on the Organ Care System (OCS) Lung. MATERIAL AND METHODS Specifics of the surgical technique for donor lung instrumentation on the OCS, lobar dissection on the OCS, and right and left donor lobectomies are presented in detail. RESULTS Potential advantages of the use of the OCS for lobectomy for lobar lung transplantation are described in this section. Donor lung volume reduction utilizing OCS appeared to be easier and safer compared to the conventional cold storage technique, due to continuous perfusion of the lungs with blood and well-distended vessels that offer the feel of live lobectomy. Moreover, the OCS represents a platform for donor organ assessment and optimization of its function before transplantation. CONCLUSIONS Donor lung volume reduction was safe and feasible utilizing the OCS, which could be a useful tool for volume reduction in cases of size mismatch. Further research is needed to evaluate early and long-term results after lobar lung transplantation using the OCS in clinical studies.

Objectives To quantify the range of blood flow parameters in ascending aorta that can result from various angulations of outflow graft anastomosis of a left ventricular assist device (LVAD) to the aortic wall, as a means to understand the mechanism of aortic valve insufficiency. Methods A realistic aorta model with LVAD anastomosis was generated from computed tomographic images of a patient. Based on this model, the LVAD anastomosis geometry parameters, such as anastomosis locations, inclination angle, and azimuthal angle (cross-sectional plane) of the graft, were varied, to create 21 models. With the assumption of no flow passing the aortic valve, and a constant flow rate from the LVAD cannula, computational fluid dynamics simulations were used to study the blood flow patterns in the ascending aorta. In addition, pulsatile flows were assumed in the LVAD cannula, with the aortic valve opened during peak systole, for 2 specific anastomosis configurations, to evaluate the influence of the pulsatile flow profile and the transvalvular flow on the aortic flow patterns. Results Changes in the inclination angle, from 60° to 120°, or the azimuthal angle, from 90° to 120°, or moving from a lower to a higher anastomosis position, causes significant changes for all flow parameters. A lower anastomosis location, an inclination angle ≥90°, and an azimuthal angle of 60° or 120° are all capable of reducing blood flow stagnation in the aortic root and producing normal wall shear stress and moderate pressure values in the region. Conclusions Carefully chosen anastomosis geometry is likely to be able to generate a close-to-normal hemodynamic environment in the aortic root. Greater knowledge of aortic valve remodeling may make possible the creation of favorable flow patterns in the aortic root, through optimization of surgical design to reduce or delay the occurrence of aortic valve insufficiency.

Roughly 60% of hearts offered for transplantation are rejected because of organ dysfunction. Moreover, hearts from circulatory-dead patients have long been thought to be non-amenable for transplantation, unlike other organs. However, tentative surgical attempts inspired by the knowledge obtained from preclinical research to recover those hearts have been performed, finally culminating in clinically successful transplants. In this review we sought to address the major concerns in non-heart-beating donor heart transplantation and highlight recently introduced developments to overcome them.

Donation after cardiocirculatory death (DCD) has lead to an increase in organ availability. However, because of medical, logistic, and ethical issues, the use of hearts from DCD donors for transplantation is not generally considered to be feasible. In this study, we investigated the feasibility of ex vivo resuscitation and assessment of the porcine heart after circulatory death using the organ care system (OCS).Cardiocirculatory death was induced in five pigs by cessation of mechanical ventilation. No heparin was administered. The agonal time (AT) was calculated as the time between a reduction of blood pressure50 mm Hg or a fall in saturation beneath 70% and the cessation of electrical activity. After a further 15 min of warm ischemia, hearts were procured and implanted into the OCS, mimicking the actual clinical scenario for other organs. Thus, procured grafts were assessed ex vivo over a period of 4 h.Four hearts were successfully resuscitated on the system (AT 8, 15, 20, and 34 min) Three grafts had excellent visual contractility and lactate trends and were considered to be transplantable. One graft (AT 34 min) had an increased lactate and abnormal contractility being unsuitable for transplantation. One heart with 48-min AT could not be resuscitated.Our data show that hearts from nonheparinized DCD porcine donors can be successfully resuscitated using the OCS in a scenario, which closely simulates clinical conditions.

Objectives Lung transplantation (LTx) remains the definitive treatment for end-stage lung failure, whereas chronic obstructive pulmonary disease (COPD) represents one of the main diagnoses leading to the indication for a transplant. We sought to assess long-term outcomes after LTx in patients diagnosed with COPD and analyze factors influencing outcome in this frequent patient cohort. Methods Between January 2007 and November 2013, a total of 88 LTx were performed in patients with COPD in our institution. Patients with emphysema associated with alpha1-antitrypsin deficiency were excluded from this observation. The study design was a retrospective review of the prospectively collected data. A large number of pre-, intra-, and postoperative variables were analyzed including long-term survival and freedom from bronchiolitis obliterans syndrome (BOS). Furthermore, impact of different variables on survival was analyzed. Results Preoperative donor data indicated a large proportion of marginal donors. While the overall cumulative survival after six yr was 57.4%, the results in terms of BOS-free survival in long-term follow-up were 39.7% after six yr. Patients with COPD were also associated with a low incidence (2.3%) of the need for postoperative extracorporeal life support (ECLS). Conclusions Long-term results after LTx in patients with COPD are acceptable with excellent survival, freedom from BOS, and low use of ECLS postoperatively despite permanently increasing proportion of marginal organs used.

Background Traditionally, patients on extracorporeal membrane oxygenation (ECMO) are sedated and mechanically ventilated, which increases risk of complications related to immobility and mechanical ventilation. The purpose of this study was to assess the feasibility and highlight the benefits of a bridge to lung transplant (LTx) using “awake ECMO” support. Methods The peripheral venovenous or venoarterial ECMO was implanted at a bedside. A retrospective study of patients undergoing LTx between January 2007 and March 2013 was performed. Outcomes in patients supported on ECMO as a bridge to LTx and kept “awake” (Group 1) were compared with the rest of the LTx patients (Group 2). Results In this period, 249 LTx were performed and in them 7 patients were bridged to LTx using “awake ECMO” strategy. Two patients were awake at ECMO implantation and throughout the therapy, and two patients were on ventilator support at the time of ECMO implantation who were extubated later and maintained awake until LTx. The remaining three patients were awake for some time during the ECMO. There was no statistically significant difference in most donor characteristics and recipient baseline characteristics as well as post-LTx parameters between the two groups. One-year survival estimate was not different between the groups: Group 1, 85.7% vs. Group 2, 86.3% (log rank p = 0.99). Conclusion In end-stage lung disease, the ECMO can be commenced in “awake” patients and patients can be awakened on ECMO. The “awake ECMO” strategy may avoid complications related to mechanical ventilation, sedation, and immobilization and provide comparable outcomes in the high-risk LTx patients.

The most extended technique of heart procurement from donors after circulatory death involves direct procurement and reperfusion in an ex situ normothermic platform using the Organ Care System (TransMedics, Inc, Andover, MA). This report describes a modified technique (at the Harefield Hospital, London, United Kingdom) with rapid donor blood drainage using a cell-saving device and synchronized perfusion on the Organ Care System.

Left ventricular assist device (LVAD) is now a routine therapy for advanced heart failure. Minimally invasive approach via thoracotomy for LVAD implantation is getting popular due to its potential advantage over the conventional sternotomy approach in terms of reduced risk at re-operation due to sternal sparing. We compared the approaches (thoracotomy and sternotomy) to determine the superiority. Minimally invasive approach involved fitting of the LVAD inflow cannula into left ventricle apex via left anterior thoracotomy and anastomosis of outflow graft to ascending aorta via right anterior thoracotomy. In the sternotomy approach, both the procedures were performed via sternotomy. Outcomes in patients after LVAD implantation were compared depending on these approaches for the surgery. Two hundred and five continuous flow LVAD implantations performed between July 2006 and June 2015 at a single center were divided based on surgical approach, that is, sternotomy (n = 180) and thoracotomy (n = 25) groups. There was no significant difference between the groups in relation to patient demographics, preoperative hemodynamic parameters, laboratory markers, or risk factors. There was no significant difference between the groups in terms of postoperative hemodynamic parameters, laboratory markers, bleeding and requirement of blood products, intensive care unit, and hospital stay or complications of LVAD surgery. There were no significant differences in terms of long-term survival (Log-Rank P = 0.953), however, thoracotomy, compared to sternotomy approach, incurred significantly less requirement of temporary right ventricular assist (4 vs. 19.4%, P = 0.041). Minimally invasive bilateral thoracotomy approach for LVAD implantation in addition to benefits of sternal sparing avoids dilatation of right ventricle and reduces chances of right ventricular failure requiring temporary right ventricular assist.

Objectives Post-cardiotomy cardiogenic shock (PCCS) results in substantial morbidity and mortality, whereas refractory cases require mechanical circulatory support (MCS). The aim of the study was to compare extracorporeal membrane oxygenation (ECMO) and ventricular assist devices (VADs) utilized in the management of PCCS. Methods In total, 56 consecutive patients who developed PCCS from 2005 to 2014 required MCS as a bridge to decision-24 were supported with a VAD and 32 with an ECMO. Groups were compared with respect to pre- and intraoperative characteristics and early and long-term outcomes to evaluate the impact of the type of MCS on complications and survival. Data are mean ± standard deviation and median with quartiles. Results EuroSCORE II was significantly higher in the VAD group than in the ECMO group (28 ± 20 vs 13 ± 16, P = 0.020) corresponding to significantly higher New York Heart Association (P = 0.031) class and Canadian Cardiovascular Society class (P = 0.040) in the cohort. The median duration of support was 10 (4-23) and 7 (4-10) days in the VAD and ECMO groups, respectively. There were no significant differences in ITU (P = 0.262), hospital stay (P = 0.193) and incidences of most postoperative complications. A significantly higher proportion of patients was successfully weaned/upgraded in the VAD group [13 (54%) vs 4 (13%), P = 0.048] with a trend towards higher discharge rate [9 (38%) vs 5 (16%), P = 0.061]. Overall cumulative survival in early follow-up [Breslow (Generalized Wilcoxon) P = 0.017] and long-term follow-up [Log-rank (Mantel-Cox) p = 0.015] was significantly better in the VAD group. Conclusions VAD and ECMO represent essential tools to support patients with PCCS. Our preliminary results might indicate some benefits of using VAD in this group of patients; however, this evidence should be further assessed in larger multicentre trials.

OBJECTIVES The presence of bacterial colonization that causes chronic pulmonary infections in cystic fibrosis (CF) patients remains a key issue before lung transplantation. We sought to assess the impact of intraoperative taurolidine lavage on bacterial colonization and long-term outcomes following lung transplantation in CF patients. METHODS Between 2007 and 2013, 114 CF patients underwent lung transplantation at our institute, and taurolidine 2% bronchial lavage was applied in a substantial proportion of patients (n = 42). A detailed analysis of donor and recipient bacterial colonization status in treatment and control groups and their impact on outcome was performed. RESULTS The proportion of recipients colonized with Pseudomonas aeruginosa was lower in the taurolidine group at 3 months (P

Closure of the chest after lung transplant in cases of oversized grafts is often difficult. Lung volume reduction and delayed closure of the chest with Bogota bag are the only options available in such situations. Here, we propose to keep the sternum and intercostal spaces open and approximate skin over it. Once lung function improves and reperfusion-related edema recovers, the chest can be closed.

Pulmonary complications after left ventricular assist device (LVAD) implantation seldom occur; however, if present, they may prove catastrophic. An Oxy-RVAD (oxygenator in right VAD circuit) is a lifesaving technique in such cases and allows freedom of introducing and removing an oxygenator into the RVAD circuit without opening the chest and competing with LVAD flow.

The discrepancy between the number of patients on the waiting list and available donor hearts has led to the successful development of left ventricular assist devices (LVAD) as a bridge to transplantation. The conventional LVADs are designed to provide full hemodynamic support for the end-stage failing heart. However, full-support LVAD implantation requires major surgery, sternotomy and cardiopulmonary bypass in majority of cases. The Synergy Micro-pump is the smallest implantable LVAD and provides partial flow support up to 3 l/min. It was shown that early intervention with this device can provide substantial benefits to patients with severe heart failure not yet sick enough for a full-support LVAD. Due the small dimensions it can be implanted without cardiopulmonary bypass or a sternotomy. The purpose of this article is to review the clinical use of the Synergy Micro-pump as partial hemodynamic support.

Background A severe shortage of available donor organs has created an impetus to use extended criteria organs for heart transplantation. Although such attempts increase donor organ availability, they may result in an adverse donor-recipient risk profile. The TransMedics Organ Care System (OCS) (TransMedics, Inc, Boston) allows preservation of the donor heart by perfusing the organ at 34°C in a beating state, potentially reducing the detrimental effect of cold storage and providing additional assessment options. We describe a single-center experience with the OCS in high-risk heart transplant procedures. Methods Thirty hearts were preserved using the OCS between February 2013 and January 2014, 26 of which (86.7%) were transplanted. Procedures were classified as high risk based on (1) donor factors, ie, transport time more than 2.5 hours with estimated ischemic time longer than 4 hours, left ventricular ejection fraction (LVEF) less than 50%, left ventricular hypertrophy (LVH), donor cardiac arrest, alcohol/drug abuse, coronary artery disease or (2) recipient factors, ie, mechanical circulatory support or elevated pulmonary vascular resistance (PVR), or both. Results Donor and recipient age was 37 ± 12 years and 43 ± 13 years, respectively. Allograft cold ischemia time was 85 ± 17 minutes and OCS perfusion time was 284 ± 90 minutes. The median intensive care unit stay was 6 days. One death (3.8%) was observed over the follow-up: 257 ± 116 (109–445 days). There was preserved allograft function in 92% of patients, with a mean LVEF of 64% ± 5%. Conclusions Use of the OCS is associated with markedly improved short-term outcomes and transplant activity by allowing use of organs previously not considered suitable for transplantation or selection of higher risk recipients, or both.

Lung transplantation (LTx) is a complex surgical procedure conventionally performed with clamps on the recipient pulmonary artery (PA) and left atrial (LA) cuff, with or without cardiopulmonary bypass (CPB). The clamps may be awkward to apply and maintain on these structures, potentially causing injury and possibly compromising the quality of anastomosis. We describe a no-clamp technique for performing these types of anastomoses.A total of 184 LTx procedures performed under CPB were grouped depending on clamping of recipient PA and LA during anastomosis using either the "no-clamp" technique (Group 1, n = 41) or the conventional technique (Group 2, n = 143). Pre-operative donor and recipient demographics and baseline characteristics as well as post-operative outcomes were compared.The demographics and pre-operative baseline characteristics of donors and recipients in both the groups were similar. Patients in Group 1 had a significantly shorter total ischemic time (p0.001), CPB time (p0.001), decreased incidence of post-LTx atrial fibrillation (p = 0.048), less need for blood and blood products transfusion, and fewer post-LTx pulmonary infections (p = 0.038). No patient in any group had post-LTx stroke. Although the incidence of post-operative bronchiolitis obliterans syndrome (BOS) did not differ between the two groups (p = 0.638), patients in Group 1 had significantly better mid- and long-term survival (p = 0.013): 89.7% vs 80%, 89.7% vs 66.5% and 89.7% vs 62.2% at 1, 3 and 6 years after LTx, respectively.The no-clamp technique for anastomosis of PA and LA in LTx is feasible and safe. It may reduce warm ischemia time as well as CPB time, with improvement in post-LTx outcomes. It may also reduce the incidence of post-LTx atrial arrhythmias.

OBJECTIVES Lung transplantation (LTx) is a life-saving therapy for patients with end-stage lung disease. However, there remains a significant postoperative complication rate and mortality in this extreme patient group. The aim of the present study was to identify donor, recipient and perioperative risk factors for one-year mortality after LTx. METHODS A total of 252 LTxs were performed in our institution between 2007 and 2013. Donor and recipient demographics and clinical characteristics of 1-year survivors and non-survivors were collected and compared retrospectively. Multivariate logistic regression analysis was performed on univariate predictors for 1-year mortality with an entry criterion of P < 0.05. RESULTS Multivariate analysis revealed female-to-male transplantation (95% CI: 0.088-0.767; P = 0.015), lower pO2/FiO2-ratio at 72 h postoperatively (95% CI: 0.988-0.999; P = 0.024), need for postoperative extracorporeal membrane oxygenation (ECMO) support (95% CI: 0.035-0.658; P = 0.012) and on-pump technique (95% CI: 0.007-0.944; P = 0.045) as the only independent predictors for 1-year mortality. Mainly unplanned intraoperative conversion to cardiopulmonary bypass contributed to poorer survival in patients who underwent LTx using cardiopulmonary bypass (P < 0.001). CONCLUSIONS Our results show that the unplanned use of CPB (conversion from off- to on-pump) might adversely affect outcome after LTx. Also, the negative impact of female-to-male transplantation should not be underestimated during recipient selection. Furthermore, poor early postoperative oxygenation, particularly with the need for extracorporeal oxygenation, might be a very strong negative prognostic factor after LTx.

In this manuscript, we present the first experience of evaluating donation after circulatory death (DCD) lungs, using the normothermic preservation Organ Care System (OCS) and subsequent successful transplantation. The OCS could be a useful tool for the evaluation of marginal lungs from DCD donors as it allows a proper recruitment and bronchoscopy in such donations in addition to continuous ex-vivo perfusion and assessment and treatment during transport. The OCS could potentially be a standard of care in the evaluation of marginal lungs from DCD.

Background Significant aortic regurgitation (AR) after continuous-flow left ventricular assist device (cf-LVAD) placement affects device performance and patient outcomes. This study examined the development of AR and long-term results after implantation of cf-LVADs. Methods The study included all patients with no or less than mild AR who underwent HeartMate II (58 [62%]; Thoratec Corp, Pleasanton, CA) or HeartWare (35 [38%]; HeartWare International, Framingham, MA) implantation at our institute from July 2006 to July 2012. Serial echocardiograms were obtained preoperatively, at 1, 3 and 6 months postoperatively, and then at a minimum of 4-month intervals in patients with longer-term support. Kaplan-Meier estimates for freedom from moderate or greater AR were generated. Logistic regression analysis was used to define independent predictors of AR after cf-LVAD implantation. Results Median duration of LVAD support was 527 days (25 th , 75 th : 289, 907; range, 60 to 2,433 days). Mild AR developed in 48 patients (51.6%) over a median duration of 126 days, with progression to moderate AR in 13 (14%) over 493 days and to severe AR in 2 (2.1%) over 1,231 days. The incidence of mild or greater AR was 43.1% in HeartMate II vs 65.7% in HeartWare recipients ( p = 0.035). Overall freedom from moderate or greater AR was 94.7% ± 2.6% at 1 year, 86.9% ± 4.5% at 2 years, 82.8% ± 5.9% at 3 years, and 31% ± 16.9% at 4 years. Independent predictors of AR were duration of support (odds ratio, 1.002; 95% confidence interval, 1.000 to 1.004; p = 0.017) and a persistently closed aortic valve (odds ratio, 0.193; 95% confidence interval, 0.097 to 0.382; p Conclusions AR is associated with longer cf-LVAD support duration and persistent aortic valve closure. Incidence of moderate or greater AR after cf-LVAD implantation increases significantly after 3 years. The clinical implications of these data may warrant consideration of prophylactic aortic valve replacement at the time of cf-LVAD implantation, particularly with expected longer duration of support and in patients with preexisting AR that is more than mild.

OBJECTIVES: Left ventricular assist devices (LVADs) are a routine treatment for patients with advanced heart failure as a bridge to transplantation. The aim of this study was to present our institutional experience and mid-term outcomes after implantation of 139 continuous-flow (cf ) LVADs as a bridge to transplantation. METHODS: One hundred and thirty-nine consecutive LVAD implantations were performed in our institution between July 2007 and August 2013. The mean age of the population was 44.0 ± 13.7 years and 24 (17%) of the patients were female. A substantial number of the patients were on preoperative mechanical support: 35 (25%) with an intra-aortic balloon pump, 9 (6.5%) with an extracorporeal membrane oxygenator and 25 (18%) with previous LVAD, for LVAD exchange. RESULTS: The mean support duration was 514 ± 481 days, whereas the longest support duration was 2493 days (>6 years). The overall cumulative survival rate following cfLVAD implantation was 89% at 30 days, 76% at 1 year and 66% at 2 years (Fig. 1). There was a statistically significant difference in survival in favour of first LVAD implantation compared with VAD exchange: 91 vs 80% at 30 days, 79 vs 57% at 1 year and 70 vs 43% at 2 years (log-rank P = 0.010). Postoperatively, patients had a significant improvement in end-organ function 1 month after LVAD implantation. In addition, comparison of two different devices [HeartMate II (HM II) and HeartWare] using propensity score matching showed no significant differences in survival and most postoperative adverse events. However, patients supported with HM II required significantly more units of fresh frozen plasma (P = 0.020) with a trend towards a higher use of red blood cells (P = 0.094), and were also more likely to develop percutaneous site infections (P = 0.022). CONCLUSIONS: HM II and HeartWare cfLVADs have excellent early postoperative outcomes and good mid-term survival, despite a considerable number of patients needing VAD exchange.

Objectives Partial-support left ventricular assist devices (LVADs) represent a novel strategy for heart failure treatment. The Synergy Pocket Micro-pump (HeartWare Inc, Framingham, Mass), the smallest surgically implanted long-term LVAD, provides partial flow up to 4.25 L/min and was primarily designed for "less sick" patients with severe heart failure. This device is implanted minimally invasively without sternotomy or cardiopulmonary bypass. Early implantation in patients with Interagency Registry for Mechanically Assisted Circulatory Support class 4 and higher was shown to be feasible and associated with significantly improved hemodynamics and quality of life. The aim of this study was to present our experience with implementation of long-term partial circulatory support as a bridge to transplantation in patients with more advanced heart failure who were dependent preoperatively on inotropic support or intra-aortic balloon pump. Methods In this observational study, only inotropic or intra-aortic balloon pump–dependent patients with end-stage heart failure were included (n = 12). These patients underwent Synergy device implantation between February 2012 and August 2013. Results The mean preoperative Interagency Registry for Mechanically Assisted Circulatory Support class was 2.17 ± 0.84 (class 1, 25%; class 2, 33%; class 3, 42%). The mean age was 46 ± 15 years, and 33% were female. Preoperatively, 4 patients (33%) had at least 1 previous sternotomy, 3 patients (25%) were supported with a balloon pump, 1 patient (8%) had a previous full-support LVAD, and 4 patients (33%) had cerebrovascular events in the past. After device implantation, there were no right ventricular failures, device-related infections, hemorrhagic strokes, arterial or venous thromboembolisms, or worsenings of aortic and mitral regurgitation observed over the follow-up. The mean follow up was 174 ± 171 days (range, 5-764 days; cumulative, 3199 days). One patient (8%) died, 3 patients (25%) successfully underwent transplantation, 1 device (8%) was explanted after myocardial recovery, and 5 patients (42%) are still on ongoing support. Two patients (17%) were upgraded to a full-support LVAD after 65 days of mean support. A total of 11 of 12 patients (92%) were discharged from the hospital and are presently alive. Left ventricular end-diastolic diameter was significantly reduced 3 months after device implantation. Conclusions Partial LVAD support may be clinically efficacious in inotropic and intra-aortic balloon pump–dependent patients. On the basis of our experience and evidence of previous research, such patients may benefit from minimally invasive access, no need for sternotomy and cardiopulmonary bypass, a short implantation time, an easy exchange if necessary, and a lower risk of subsequent heart transplantation. Because the implantation is performed without sternotomy, device upgrade is feasible with a comparatively low operative risk and good clinical outcome. Our preliminary results show that partial-support devices may have the potential to replace full-support LVADs in the near future.

The purpose of this study was to evaluate gender differences regarding outcome after continuous-flow left ventricular assist device (cfLVAD) implantation. The study was a retrospective review of prospectively collected data. Included were 24 consecutive female cfLVAD recipients and 24 male recipients (62.5% HeartMate II, 37.5% HeartWare) who received their devices between July 2007 and May 2013. Subjects were matched using propensity score analysis based on age, diagnosis, body surface area, preoperative mechanical circulatory support, heart failure severity score (INTERMACS class), and comorbidities. Female patients were significantly sicker before operation. After propensity score matching, there were no statistically significant differences in demographics or clinical baseline characteristics between male and female LVAD recipients. Also, there was a trend towards a longer postoperative intensive care unit stay in the female group (median 9 days [interquartile range 5-17] versus 15 days [interquartile range 8-33]; P < 0.061) and higher postoperative bilirubin values (median 14 mmol/L [interquartile range 10-17] versus 21 mmol/L [interquartile range 13-30]). However, there were no significant differences between the two groups in terms of outcome (P < 0.569). The overall survival was comparable between the two groups (log rank P < 0.389). Half (50%) of female patients required inotropic support for more than 7 days compared with 21.7% in the male group (P < 0.048). Half (50%) of female recipients required short-term postoperative right ventricular assist device implantation compared with 16.7% in the male group (P < 0.014). In conclusion, cfLVAD implantation as a bridge to transplantation is associated with longer duration of inotropic support and higher requirement for postoperative mechanical right ventricular support in women with similar survival rates. Further studies are required to identify additional demographic and clinical factors that modulate outcomes and will enhance the ability to risk-stratify cfLVAD recipients.

OBJECTIVES: The Synergy® CircuLite® micropump is a novel partial-support miniature left ventricular assist device that propels 2– 3l /min blood from the left atrium into the right subclavian artery. The ability of currently available investigative modalities to confirm Synergy pump malfunction is limited. The Synergy speed fluctuates periodically (at 10-s intervals) from the baseline to a transient decrease followed by a transient increase (alternating speed algorithm, ASA) with the purpose of changing the blood flow behaviour, thereby reducing thrombogenicity. The aim of this study was to develop a simple non-invasive monitoring technique to assess pump function based on the detection of the ASA in the peripheral microcirculation. METHODS: Between February 2012 and July 2013, 10 patients with advanced chronic heart failure underwent Synergy implantation at our institution. The pump function was assessed by echocardiography and invasive monitoring according to standard protocols; additionally, the pump speed and power consumption were monitored. During the pump function assessment, the pulse oximeter waveform was recorded from the index fingers of the left and right hand with simultaneous pump auscultation using a stethoscope positioned on the pump (right infra-clavicular pocket). RESULTS: The pulse oximeter waveform was readily detectable from the right and left hand of all study patients. If the Synergy function was normal, there was a significant difference in the morphology of the pulse oximeter waveform from each hand: the ASA algorithm produced a more pronounced variation (giant wave) in the trace from the right hand than from the left. The giant waves invariably coincided with the sound variation associated with the ASA algorithms, which were detected regularly at 10-s intervals. CONCLUSIONS: We describe a simple, readily applicable, inexpensive, non-invasive technique that allows evaluation of Synergy pump function and may have diagnostic utility under conditions of suspected pump thrombus/malfunction. This technique is readily applicable from the early post-implant period throughout support and allows clinical personnel to verify blood flow variation through the Synergy, thereby providing a novel method of assessing device function.

Post-cardiotomy cardiogenic shock (PCCS) results in substantial morbidity and mortality, whereas refractory cases require mechanical circulatory support. The aim of this study was to evaluate factors influencing survival during short-term ventricular assist support in PCCS. In total, 154 CentriMag(®) (Thoratec; CA, USA) devices were implanted for cardiogenic shock between 2004 and 2011 out of which 31 were for PCCS. A retrospective review was performed in 31 PCCS patients who required the CentriMag short-term VAD as a bridge to decision. Survivors and non-survivors were compared with respect to pre- and intra-operative characteristics as well as duration of short-term VAD support. Mean duration of support was 11.7 ± 15.4 days (range 1-65 days). Seventeen (54.83 %) patients died on support, 14 (45.16 %) were weaned off or upgraded to long-term device, while 11 (35.5 %) were discharged home. The overall survival to myocardial recovery and device explantation, or upgrade to a long-term VAD, was 41.9 % (n = 13) at the study cutoff. EuroSCORE II was significantly higher in non-survivors as compared to survivors (p = 0.047). The duration of short-term VAD support was significantly longer in survivors (p 0.001). The CentriMag is a versatile, safe and effective short-term circulatory support for patients with PCCS as a bridge to decision which enables longer support and better recovery of both heart and end-organ function and thus may improve the survival of PCCS patients. Lower EuroSCORE may be essential for myocardial recovery in PCCS.

Extracorporeal membrane oxygenation (ECMO) is a temporary mechanical circulatory assist method that offers circulatory as well as respiratory support efficiently via peripheral access; however, it is liable to complications. Limb ischemia is one of the notorious complications of ECMO but can be avoided utilizing a proper distal limb perfusion method. A retrospective study of patients undergoing peripheral venoarterial (VA) ECMO for various reasons between June 2010 and December 2012 was performed. All patients were evaluated by our multidisciplinary team for suitability as candidates for ECMO. A peripheral VA-ECMO circuit was implanted via groin: inflow cannula in the femoral vein, an outflow cannula and distal-perfusion cannula, or an introducer sheath in the femoral artery. During the study period, 83 patients underwent various types of ECMO; 45 received peripheral VA-ECMO. Distal limb perfusion was achieved with an introducer sheath (6-8 Fr) in 13 cases and with a distal-perfusion cannula (10-12 Fr) in 32 cases. Nine (20%) patients developed signs of ischemia; five (11.2%) were treated conservatively, while four (8.8%) required surgical intervention. One patient required a below-knee amputation. The incidences of limb ischemia and limb ischemia requiring surgical intervention were significantly higher for the introducer sheath compared with the cannula (30.6 vs. 15.6% and 15.4 vs. 6.25%, respectively). Moreover, the patients supported on ECMO with a distal-perfusion cannula spent a significantly longer time on ECMO compared with the ones in whom an introducer sheath was used (11.9 ± 9.1 vs. 7.7 ± 4.3 days). The mean cannula size was significantly greater than the mean introducer sheath size (11.1 ± 1.3 vs. 7.0 ± 1.1 Fr). Use of a distal-perfusion cannula is a most reliable method of limb perfusion in peripheral VA-ECMO. The cannula can ensure adequate and smooth perfusion of the limb owing to its large caliber, its less turbulent flow, the ability it provides to monitor the flow, and the option to attach a side port.

Left ventricular assist devices (LVADs) are fast becoming standard of care for patients with advanced heart failure. However, despite continuous improvement in VAD technology, there remains a significant early postoperative morbidity and mortality in this extreme patient group. The aim of the current study was to explore the short-term outcomes and predictors for 90 day mortality in the patients after implantation of continuous-flow LVAD. Perioperative clinical, echocardiographic, hemodynamic, and laboratory data of 90 day survivors and nonsurvivors were collected and compared retrospectively. Multivariate logistic regression analysis was performed on univariate predictors for 90 day mortality with an entry criterion of p < 0.1. Between July 2006 and May 2012, 117 patients underwent implantation of a continuous-flow LVAD as a bridge to transplantation: 71 (60.7%) HeartMate II (Thoratec Corp, Pleasanton, CA) and 46 (39.3%) HVAD (HeartWare International, Framingham, MA). All-cause 90 day mortality was 17.1%. Multivariate analysis revealed higher preoperative central venous pressure (odds ratio [OR], 1.18; 95% confidence interval [CI], 1.014–1.378; p = 0.033) and higher age (OR, 1.14; 95% CI, 1.01–1.38; p = 0.045) as the only independent predictors for 90 day mortality. Optimization of preoperative volume status, preload, and right heart function as well as age-based selection of candidates for LVAD support are the critical factors influencing early outcome after continuous-flow LVAD implantation.

Lung transplantation (LTx) is significantly limited by donor organ shortage. Donor smoking history of more than 20 pack-years is considered an extended donor criterion. In this study, we retrospectively evaluated impact of donor smoking history and extent of smoking on midterm outcome after LTx.In all, 237 LTx were performed in our institution between 2007 and 2012. Patients were divided into three groups, receiving lungs from 53% nonsmoking donors, 29% smoking donors with fewer than 20 pack-years, and 18% heavy smokers with more than 20 pack-years.Preoperative donor and recipient characteristics among the groups were comparable. However, donors from the heavy smokers group were significantly older (p0.001). The overall presence of abnormal histology (inflammation or metaplasia) in donor main bronchi samples increased with the extent of smoking but did not reach statistical significance (p = 0.211). Although metaplasia was found in significantly more donors from the heavy smokers group (p = 0.037), this did not translate into inferior outcomes for the recipients. There were no statistically significant differences in PaO2/FiO2 ratio after LTx, duration of mechanical ventilation (p = 0.136), intensive care unit stay (p = 0.133), and total postoperative hospital stay (p = 0.322). One-year and three-year survival were comparable across all three groups (log rank p = 0.151). Prevalence of bronchiolitis obliterans syndrome (p = 0.616), as well as bronchiolitis obliterans syndrome free survival (p = 0.898) after LTx were also comparable.In our experience, history and extent of donor smoking do not significantly affect early and midterm outcomes after LTx. Although this finding does not obviate the need for longer-term observation, donor lungs from even heavy smokers may not per se contraindicate LTx and may provide a valuable avenue for expanding donor organ availability.

In today's era, given the worsening risk profiles of patients undergoing cardiac surgery, the increasing number of complex cardiac surgeries, and the increasing number of patients undergoing thoracic organ transplantation, short-term mechanical circulatory assist (MCA) devices are indispensable. MCA devices are capable of supporting heart and lung function and have emerged as potentially lifesaving instruments, but may prove to be as hazardous as helpful due to their inherent tendency toward hemolysis, thromboembolism, and hemorrhage. Although MCA devices are being used regularly at some specialized centers, surgeries involving MCA are not as common as other routine cardiac surgeries, and even though professionals implanting and maintaining short-term MCAs are well acquainted with operating such devices, it is not uncommon to come across complications as a result of minor mistakes committed while dealing with them. Avoiding simple mistakes and taking proper precautions while implanting and maintaining these devices can prevent major catastrophes. We discuss commonly encountered problems and complications during the implantation and maintenance of short-term MCAs and offer reasonable and practical solutions. In addition, crucial issues such as anticoagulation, replacement of the device circuit, and management of the distal perfusion cannula are discussed. Continuous and efficient monitoring of the MCA device and the patient supported on MCA, together with anticipation and avoidance of complications, is key for successful short-term MCA support.

Patients with idiopathic pulmonary artery hypertension in refractory right ventricular failure may decompensate acutely and die while on the lung transplantation waiting list. We describe such a patient bridged to lung transplantation with a modified surgical technique for left pulmonary artery-to-left atrium bypass using Novalung, a low-resistance diffusion membrane device.

Chronic heart failure is a progressive and eventually fatal illness. Although the disease cannot be cured and treatment is symptom oriented, most of the patients benefit from optimum medical treatment. Patients with rapid deterioration in chronic advanced heart failure refractory to medical treatment need inotropic support and may need intra-aortic balloon pump to maintain circulatory support, which of course cannot be prolonged beyond a certain limit. The outcome of heart transplant and long-term ventricular assist device (VAD) in such patients is poor. The short-term mechanical circulatory support (MCS) offered to such patients not only provides effective circulatory support and stabilizes them hemodynamically, but also halts the ensuing or reverts the established end-organ failure. As the name suggests, the short-term MCS offers support for the short term, usually less than a month. Although some patients with acute heart failure experience recovery of myocardial function with short-term MCS support, others become dependent. These patients, stabilized and "stuck" with short-term MCS, can be "rescued" with long-term VAD or heart transplantation. Both the procedures, when done in this special situation, have their inherent advantages, disadvantages, and complications and hence need the careful consideration about the choice of the procedure. We have tried to elucidate this situation by considering the advantages and disadvantages of both options.

Heart failure is a progressive disease with limited treatment options. The C-Pulse Heart Assist System (Eden Prairie, MN) is an extravascular, diastolic counterpulsation circulatory support device for patients with refractory NHYA Class III/ambulatory class IV heart failure. It comprises a balloon-cuff which is implanted around the ascending aorta that is synchronised to inflate during ventricular diastole. The system eliminates the need for systemic anticoagulation and significantly reduces the risk of bleeding and overcomes the problem of device thrombosis. However, clinical efficacy is dependent on maintenance of residual myocardial function. We describe a case of a patient who presented with ischemic cardiomyopathy in end-stage heart failure and received the C-Pulse System. Due to deterioration in cardiac function, the system had to be upgraded to a full-support left ventricular assist device (LVAD) after 4 months. However, the aorta ascendens was short and the outflow graft of the HeartWare LVAD had to be anastomosed to the cuff balloon region of the aorta. Our experience showed in this case that the inflatable cuff action did not compromise the structural integrity of the aortic wall.

Spontaneous left main coronary artery dissection is a rare cause of acute coronary events or sudden cardiac death, constituting less than 1% of all epicardial coronary artery dissections. It is often fatal and is mostly recognized at post-mortem examination in young victims of sudden death. More than 70% of the reported cases occurred in women, particularly during pregnancy and the peripartum period and those on oral contraceptives. The clinical presentation is highly variable and prognosis varies widely, depending predominantly on the speed of diagnosis. Treatment options include medical therapy, revascularization with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) and mechanical circulatory support in cases of cardiogenic shock. We report a case of spontaneous dissection of the left main stem coronary artery, with extension into the left coronary territory, which occurred in a 41-year-old lady, complicated by profound cardiogenic shock requiring recovery with extracorporeal mechanical circulatory support after salvage myocardial revascularization.

Purpose Low cardiac output syndrome is associated with significant mortality. In patients with refractory low cardiac output left ventricular assist devices (VAD) are used to re-establish cardiac output and to prevent death. However, long-term LVAD implantation in these is complicated by a high rate of right heart failure and mortality. Therefore, our strategy is to implant a short-term VAD (left or biventricular) as a bridge to decission. Methods We retrospectively analysed data from 66 patients who received a short-term LVAD support prior to implantation of a long-term LVAD or HTx between 2003 and 2014. We performed short-term LVAD (CentriMag; Thoratec) implantation via median sternotomy with percutaneous cannulas. Patients were included regardless of perioperative status and severity of heart failure. Patients suffering postcardiotomy cardiogenic shock, receiving isolated RVAD as well as posttransplant patients were excluded from this study. Results Mean duration of support in the survivor group was 35 ± 25 days versus 25 ± 25 days in the nonsurvivor group (n.s.), range from 1 to 109 days. The overall survival on support was 40 (60%) patients. In the survivor group 12 patients could be successfully weaned from the system, 12 patients received a heart transplant and in 16 a long-term VAD was implanted. In the nonsurvivor group the rate of pre-operative extracorporeal life support, the rate of postoperative renal failure and multiorgan failure was significantly higher. Conclusions Thanks to its capacity for full ventricular support, short-term univentricular or biventricular LevotronixCentriMag VAD currently represents an ideal solution for bridge-to-decision.

Left ventricular assist device (LVAD) is now a routine therapy for advanced heart failure. Authors demonstrate a novel technique of LVAD implantation through a single left thoracotomy with anastomosis of outflow graft to the arch of aorta. The technique avoids sternotomy or additional right thoracotomy, keeps ascending aorta clear and puts outflow graft away from the sternum.