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Ventricular septal defect (VSD) is a rare but severe complication of myocardial infarction (MI). Temporary mechanical circulatory support (MCS) can be used as a bridge to VSD closure, heart transplantation, or ventricular assist device. We describe the use of Impella device in this context based on a multicenter European retrospective registry (17 centers responded). Twenty-eight post-MI VSD patients were included (Impella device were 2.5 for 1 patient, CP for 20, 5.0 for 5, and unknown for 2). All patients were in cardiogenic shock with multiple organ failure (SAPS II 41 [interquantile range {IQR} = 27–53], lactate 4.0 ± 3.5 mmol/L) and catecholamine support (dobutamine 55% and norepinephrine 96%). Additional temporary MCS was used in 14 patients (50%), mainly extracorporeal life support (ECLS) (n = 9, 32%). Severe bleedings were frequent (50%). In-hospital and 1 year mortalities were 75%. Ventricular septal defect management was surgical for 36% of patients, percutaneous for 21%, and conservative for 43%. Only surgically managed patients survived (70% in-hospital survival). Type and combination of temporary MCS used were not associated with mortality (Impella alone or in combination with intra-aortic balloon pump [IABP] or ECLS, p= 0.84). Impella use in patients with post-MI VSD is feasible but larger prospective registries are necessary to further elucidate potential benefits of left ventricular unloading in this setting.

Circulatory support with a catheter-based microaxial flow pump (mAFP) plays a major role in the treatment of severe cardiogenic shock. In most patients who fail to recover while on temporary mechanical circulatory support (tMCS) and who are not eligible for heart transplantation, durable left ventricular assist device (dLVAD) implantation is usually considered a reliable option. This study aimed to describe the outcome of dLVAD therapy following mAFP support and to identify predictors of mortality.

Transaxillary implantation of a temporary microaxial left ventricular assist device in patients suffering from cardiogenic shock is an established technique. We present a 77-year-old female patient with severe mitral regurgitation. She underwent minimally invasive surgical mitral valve replacement. After an uneventful postoperative course, the patient developed acute heart failure on the 11thpostoperative day. Transthoracic echocardiography revealed new onset of Takotsubo cardiomyopathy with a severely decreased left ventricular ejection fraction. Implantation of a microaxial flow pump for left ventricular decompression was scheduled. Preoperative computed tomography revealed a rectangular course of the right subclavian artery. To advance the Impella, we employed an introducer fitted over the guidewire behind the Impella device as a ‘cue stick’ to move the rigid part of the pump forward to overcome the kinking using a ‘shuffleboard technique’. The haemodynamic situation stabilized immediately after implantation. The Impella 5.5 was successfully weaned after 6 days of support. In the event of (rectangular) kinking of the subclavian artery, the ‘shuffleboard technique’ can be used for the successful positioning of the pump.Transaxillary implantation of a temporary microaxial left ventricular assist device (Impella 5.5, Abiomed Inc., USA) in patients suffering from cardiogenic shock is an established technique [1].

Exchange of the HeartWare HVAD made necessary by thrombosis or cable damage is rare, but it is a complex procedure associated with morbidity. Less invasive exchange procedures may contribute to faster postoperative recovery and early mobilization. Between September 2009 and April 2012, 225 patients (median age 55.4 years, range 7–82 years, 40 of them women) were supported with the HeartWare HVAD at our institution. Cumulative follow-up in all 225 patients was 151.9 patientyears. In six patients, early pump thrombosis (<30 days) requiring pump exchange occurred after a median time of 7 (2–9) days. In six patients, late pump thrombosis requiring pump exchange occurred after a median of 380 (84–705) days. The overall incidence was 5.3 with 0.079 thromboses per year. In two instances of accidental cable damage as a result of massive external mechanical impact, pump exchange was necessary. We describe a safe and less invasive technique for the explantation and exchange of the HeartWare HVAD through a left thoracotomy. Pump thrombosis of the HeartWare HVAD is a very rare condition caused mostly by new onset of heparin-induced thrombocytopenia type II, mismanagement of anticoagulation, or hypercoagulability in the case of severe sepsis. Since the introduction of the sintered inflow cannula no early thrombosis has occurred. Pump exchange in the case of hemolysis should not be delayed. The cable of the HeartWare HVAD is very reliable and breaks only after excessive external impact. A minimally invasive approach for pump exchange on cardiopulmonary bypass for pump thrombosis and off-pump for cable damage or pump explantation is recommended.

Implantable continuous flow pumps are a routine treatment for end-stage heart failure. The waiting time for heart transplantation is increasing, and more and more patients receive the pump for permanent support. We retrospectively analyzed our database of patients supported with the HeartMate II left ventricular assist device to identify instances of cable damage. Between May 9, 2006 and May 9, 2012, 161 patients were supported with the HeartMate II. There were 187 cumulative years of HeartMate II support. The documented cable damage occurred in 12 patients (7.5), requiring pump exchange in five patients after a mean time of 706 days on support. There was no perioperative mortality. The damage occurred typically at the “weak” place–the feedthrough of the driveline to the pump body. In some cases, the device alarm history and x-ray may allow diagnosis before pump stop occurs. However, since the most recent changes in the design of the connection and modifications made in the implantation technique, no instance of cable damage has been registered.

Introduction: Aortic valve regurgitation or the presence of a mechanical aortic valve prosthesis is a relative contraindication for implantation of left ventricular assist devices (LVAD). However, concomitant aortic valve replacement by a biological prosthesis is one of the options in this situation. We analyzed our recent experience with left ventricular assist device implantation and concomitant aortic valve replacement.Methods: Between January 1, 2008 and January 15, 2012, 318 adult patients (>18 years old) were supported with a long-term implantable LVAD in our institution. In 19, simultaneous aortic valve replacement (6 redo and 13 primary procedures) was performed. Patients were divided into 2 groups according to INTERMACS (IM) level: Group 1 (n = 7) consisted of patients with IM level 1–2 and Group 2 (n = 12) of IM level 3–4 patients. As a control cohort we analyzed all LVAD recipients during the study period (n = 299, study group excluded). The control cohort was similarly divided into two groups according to the IM level: Group 3 (n = 162) consisted of patients with IM level 1–2 and Group 4 (n = 137) of those with IM level 3–5. Perioperative data and outcomes in all groups were retrospectively analyzed and compared (Group 1 compared to Group 3; and Group 2 to Group 4).Results: In study Groups 1 and 2 all patients were male; in Groups 3 and 4, 80% and 88% respectively were male. Median age distribution in Groups was 55, 61, 54, and 57 years respectively. Patients from Group 2 were significantly older than those from Group 4 (p = 0.039). Body mass index was significantly lower in Group 1 than in Group 3 (p = 0.033). Cardio-pulmonary bypass time was significantly longer in Groups 1 and 2 compared with Groups 3 and 4 respectively (p=0.001). Patients from Group 1 had a trend more often to develop right ventricular failure requiring a right ventricular assist device (RVAD) than those in Group 3 (p = 0.09). Intensive care unit stay duration of mechanical ventilation and in-hospital mortality in Group 1 were significantly higher than in Group 3 (p = 0.025, p = 0.005, p = 0.038). Patients from Group 2 had similar outcomes compared to those from Group 4.Conclusions: In stable patients, simultaneous aortic valve replacement and LVAD implantation are not associated with an impaired outcome. In patients with cardiogenic shock an additional aortic valve replacement may impair outcome; therefore alternative techniques should be considered.

Little is known about the hemolysis rate in the case of concomitant implantation of two continuous flow pumps for the treatment of biventricular heart failure. We present a retrospective study comparing the hemolysis parameters in patients supported with one implantable centrifugal pump of the type HeartWare HVAD used as a left ventricular assist device (LVAD) and with two pumps as a biventricular assist device (BiVAD). A total of 20 consecutive patients who received HeartWare BiVAD (n 10) and LVAD (n 10) support at our institution between September 2009 and September 2010 were examined. Hemolysis- and anemia-related parameters were analyzed after 2 weeks, 5 weeks, 3 months, and 6 months of support. Preoperative levels of hemoglobin, lactate dehydrogenase (LDH), and total bilirubin were similar in both groups. There were no differences in LDH, plasma-free hemoglobin (fHB), or total bilirubin levels postoperatively for up to 6 months. Only the haptoglobin level was lower in BiVAD recipients up to 3 months after surgery: 2nd week (63.5 range: 8–237 mg/dl vs. 151 range: 11–263 mg/dl, p0.05), 5th week (67 range: 8–196 mg/dl vs. 215 range: 56–292 mg/dl, p0.046), and after 3rd month (42 range: 8–205 mg/dl vs. 220 range: 157–256 mg/dl, p0.048). Our retrospective analysis of BiVAD HeartWare and LVAD HeartWare recipients showed a lack of a clinically important degree of hemolysis when two centrifugal HeartWare pumps are used for biventricular support.

In patients with end-stage heart failure, severe tricuspid regurgitation (TR) might be one of the signs of biventricular failure with subsequent need for biventricular support (biventricular assist device BVAD) or total artificial heart (TAH). However, tricuspid valve repair (TVR) may avoid BVAD or TAH implantation. Consecutive patients with TR of grade 3 receiving either left ventricular assist device with concomitant TVR (group A, n 7) or a BVAD/TAH (group B, n 18) implanted in our institution between 2007 and 2010 were compared retrospectively. Intermacs (Interagency Registry for Mechanically Assisted Circulatory Support) stage I, age less than 18 years, and postcardiotomy failure were the exclusion criteria. Preoperative parameters were similar in both groups. No differences in 30-day mortality (28.5% vs. 22.2%, p0.8), postoperative dialysis, intensive care unit (ICU) stay (35 vs. 22 days, p0.94), or ventilation time (15 vs. 13 days) were seen. Timing of discharge home was similar in both groups (42.8% after a median of 45 days vs. 50% after a median of 40 days p0.78). Six months after surgery, no significant TR was seen in group A. Right ventricular failure requiring mechanical support occurred in 14.2% (n 1) in group A. In patients with TR of grade 3, left ventricular assist device support combined with TVR showed comparable results with biventricular support with regard to short-term outcome. These results led to a change of our established ventricular assist device implantation strategy.

As permanent support with ventricular assist devices (VADs) has become a reality and increasing numbers of patients are being supported for several years, the interactions between the VAD and the body and the management of complications during life-long support have gained the interest of clinicians and biomedical engineers.

Mechanical circulatory support (MCS) is valuable in saving the lives of patients with severe cardiogenic shock. However, their survival is limited if multiorgan failure (MOF) proves to be irreversible. Although ventricular assist devices (VADs) have been shown to reverse end-organ failure in some patients, the pathophysiological mechanisms of end-organ failure and its regression are not fully understood, and clinical markers and thresholds for the “point of no return” are lacking. We investigated predictors of 30-day survival in patients supported with a biventricular assist device (BVAD). We studied 157 patients implanted with a Berlin Heart EXCOR BVAD between 1987 and 2006. Children younger than 10 years and cases with postcardiotomy syndrome and transplant failure were excluded from the analysis as well as patients with technical or bleeding problems requiring rethoracotomy. In total, 69 clinical, hemodynamic, echocardiographic, and laboratory parameters were evaluated. Most of the patients suffered from ischemic cardiomyopathy or acute myocardial infarction. In addition, the preoperative multiple organ dysfunction syndrome (MODS) and the sequential organ failure assessment (SOFA) scores were calculated. The patients were divided into two groups regarding procedural success: group I—survival >30 days or heart transplantation or weaning from device (n 105) and group II—death on system <30 days after surgery (n 52). The 30-day procedural success rate was 67%. The patients in group I had higher systolic blood pressure (96.7 vs.90.1 mm Hg, p0.027), lower serum creatinine (1.96 vs.2.4 mg/dl, p0.001), and higher arterial pH (7.43 vs.7.37, p0.02). The multivariate analysis recognized age, body temperature, systolic blood pressure, MODS score, and higher arterial pH as significant predictors for 30-day mortality. Standard markers for severity of cardiogenic shock and MOF do not predict survival on BVAD. As expected, older patients are at higher risk for death on BVAD. Acidosis and high MODS score predict unfavorable outcome. However, the prediction of clinical outcome in patients in severe cardiogenic shock supported by BVAD is possible in extreme situations only.

Implantation of a left ventricular assist device (LVAD) is an established treatment in end-stage heart failure. The longevity of LVAD support systems remains uncertain to a great extent because patients usually undergo transplantation, are weaned or die while on support before the maximum service life of these pumps is reached. We report about the hitherto longest published and still ongoing LVAD support of a 65 year old patient who received an Incor LVAD (Berlin Heart, Berlin, Germany, produced 2002–2018) 13 years ago. After pump exchange due to driveline damage, the patients were discharged home.

One approach to the tissue engineering of vascular structures is to develop in vitro conditions in order ultimately to fabricate functional vascular tissues before final implantation. In our experiment, we aimed to develop a new combined cell seeding and perfusion system that provides sterile conditions during cell seeding and biomechanical stimuli in order to fabricate autologous human vascular tissue in vitro. The cell seeding and perfusion system is made of Plexiglas and is completely transparent (Berlin Heart, Berlin, Germany; University Hospital Benjamin Franklin, Berlin, Germany). The whole system consists of a cell seeding chamber that can be incorporated into the perfusion system and an air-driven respirator pump connected to the bioreactor. The cell culture medium continuously circulates through a closed-loop system. We thus developed a cell seeding device for static and dynamic seeding of vascular cells onto a polymeric vascular scaffold and a closed-loop perfused bioreactor for long-term vascular conditioning. The cell seeding chamber can be easily connected to the bioreactor, which combines continuous, pulsatile perfusion and mechanical stimulation to the tissue-engineered conduit. Adjusting the stroke volume, the stroke rate, and the inspiration/expiration time of the ventilator allows various pulsatile flows and different levels of pressure. The whole system is a highly isolated cell culture setting, which provides a high level of sterility and a gas supply and fits into a standard humidified incubator. The device can be sterilized by ethylene oxide and assembled with a standard screwdriver. Our newly developed combination of a cell seeding and conditioning device provides sterile conditions and biodynamic stimuli for controlled tissue development and in vitro conditioning of an autologous tissue-engineered vessel.

Hintergrund: Herzversagen ist die führende Todesursache in den hoch entwickelten Ländern. Bei therapierefraktärem Herzversagen ist eine Herztransplantation oder die Übernahme der nativen Herzfunktion durch eine künstliche Blutpumpe notwendig. Obwohl die Herztransplantation ausgezeichnete Langzeitergebnisse mit 10-Jahres-Überlebensraten um 50% bietet, bleibt sie angesichts der geringen Fallzahlen eine kasuistische Therapie. Herzunterstützungssysteme: Der aktuelle Entwicklungsstand künstlicher Herzunterstützungssysteme wird repräsentiert durch die breite Verfügbarkeit elektrisch betriebener linksventrikulärer Assist-Pumpen (LVAD), die noch ein perkutan ausgeleitetes Steuerungs- und Energieversorgungskabel zur Konnektion an externe Quellen benötigen, während die Pumpe selbst intrakorporal implantiert ist. Die unlängst in die klinische Therapie eingeführten Axialflusssysteme (DeBakey-, Jarvik-2000- und Heart-Mate-II-LVAD) bieten bei kontinuierlichem Blutfluss durch ihre geringe Größe und Gewicht, geringen Energieverbrauch, vereinfachte Implantationstechnik und Steuerung offenbar deutliche Vorteile gegenüber den bereits längere Zeit verwendeten pulsatilen Blutpumpen (Novacor-N100-, TCI-HeartMate-LVAD). Die ersten zum permanenten Herzersatz verfügbaren, komplett intrakorporal implantierbaren Systeme (Lion-Heart-LVAD, AbioCor-Kunstherz) sind noch zu kurzfristig in der klinischen Anwendung, um ihr Leistungspotential zu bewerten. Indikationen: Weltweit etablierte Indikationen zur Anwendung von künstlichen Blutpumpen sind das Bridge-to-Transplant-Verfahren, welches der primären Herztransplantation vergleichbare Ergebnisse liefert, und das akute Herzversagen, entweder nach Myokardinfarkt oder nach einem herzchirurgischen Eingriff. Im Säuglings- oder kindesalter konnten mit verkleinerten Blutpumpen des Berlin-Heart-Systems gute Erfolge in der Behandlung des Herzversagens bei Myokarditis und bei dilatativer Kardiomyopathie erzielt werden. Angesichts der hohen Inzidenz von Herzversagen - vor allem bei älteren Patienten - erscheint ein langfristiger Einsatz von Blutpumpen gerechtfertigt. Background: Heart failure is the leading cause of death in the developed countries. Organ-preserving operative procedures on the failing heart like coronary artery bypass procedures or resection of left ventricular aneurysms are part of the routine care in cardiac surgery today. Terminal heart failure refractory to optimized drug therapy, however, will require a heart transplantation of the implantation of artificial blood pumps. While heart transplantation has proven to provide excellent long-term results with 10-year survival rates at 50%, it will remain a casuistic therapy, limited by the comparatively small number of procedures which can be performed. Artificial Blood Pumps: The current status of development of artificial blood pumps is represented by the broad availability of partially-implantable electric motor-driven left ventricular assist devices (LVAD), which still require a percutaneous cable for energy supply and device control from external sources while the blood pump itself resides inside the body. The recently introduced axial-flow devices (De-Bakey, Jarvik 2000 and HeartMate II LVADs) deliver a continuous blood flow and obviously provide distinct advantages with regard to a reduction in size, weight and energy demands, simplified implantation technique and device control when compared to the previously available partially-implantable electric motor-driven pulsatile blood pumps (Novacor N100, TCI Heart Mate LVADs). The first systems designed for long-term or permanent use (Lion Heart LVAD, Abio-Cor replacement heart) are completely implantable devices featuring percutaneous energy transmission and device control. However, the latter are more complex devices and their clinical application is still limited to a small number of cases, which precludes a judgement about their potential at this time. Indications: The use of paracorporeal pneumatically accentuated blood pump systems is still indicated in cases of most severe biventricular heart failure and multiorgan failure or if only short- to mid-term circulatory support is anticipated. Well established indications for utilization of artificial blood pumps are the bridge-to-transplant procedure, which yields results comparable to primary heart transplantation, and acute cardiac failure following myocardical infarction or cardiac surgical procedures. In newborns and children, encouraging results were obtained when miniaturized blood pumps of the Berlin Heart System were utilized for heart failure in myocarditis or dilative cardiomyopathy. With advanced reliability of artificial blood pumps and in face of the high incidence of heart failure, especially in the older age group, the long-term application of artificial bloods pump appears to be justified.

OBJECTIVES

Cardiac troponin I and T (cTnI and cTnT) are sensitive andspecific markers of myocardial damage. We evaluated them for the selection ofheart donors and as predictors of early graft failure after hearttransplantation.

Objective:Coating of ventricular assist devices (VADs) with heparin improves the biocompatibility and may reduce the need for systemic anticoagulation. However, heparins are associated with the risk of formation of heparin/platelet factor 4 antibodies (HPF4/A) and the development of heparin-associated thromboemboli. We analyzed the occurrence of HPF4/A and thromboembolism in patients with heparin-coated and noncoated VADs. Methods:One hundred patients were enrolled in the investigation. Fifty-seven received a heparin-coated (group 1) and 43 a noncoated (group 2) VAD. HPF4/A testing was performed before and 2 and 12 weeks after implantation by the heparin platelet factor 4 enzyme-linked immunosorbent assay. Results:There was no significant difference in the occurrence of HPF4/A in the 2 groups (P=.102). Before the operation, 21 of the patients in group 1 had positive test responses and 25 in group 2. No patient had HPF4/A after termination of systemic heparinization. In group 1 there was no significant difference in the incidence of recurrent pump thromboses in patients who had positive test responses for HPF4/A (n = 11) when compared with those who had negative test responses (n = 9, P=.89). Twenty-one patients had HPF/A but no thromboembolism. However, all 22 patients who had thromboembolism had HPF4/A. Conclusions:Heparin coating of the VAD surface does not enhance the occurrence of HPF4/A-associated immunologic or thrombogenic reactions. However, the presence of these antibodies is strongly associated with an increased risk of thromboembolism in patients with a VAD. (J Thorac Cardiovasc Surg 2001;121:331-5)

The continual shortage of hearts for transplantation (HTx) led to the expansion of the donor pool by accepting older donors. We compared the medium-term follow-up of patients after HTx with older hearts (over the age of 63 years) with those of patients after HTx with younger hearts.

The coronavirus disease 2019 (COVID-19) pandemic has potentiated the need for implementation of strict safety measures in the medical care of surgical patients – and especially in cardiac surgery patients, who are at a higher risk of COVID-19-associated morbidity and mortality. Such measures not only require minimization of patients’ exposure to COVID-19 but also careful balancing of the risks of postponing nonemergent surgical procedures and providing appropriate and timely surgical care. We provide an overview of current evidence for preoperative strategies used in cardiac surgery patients, including risk stratification, telemedicine, logistical challenges during inpatient care, appropriate screening capacity, and decision-making on when to safely operate on COVID-19 patients. Further, we focus on perioperative measures such as safe operating room management and address the dilemma over when to perform cardiovascular surgical procedures in patients at risk.

We report the successful use of the implantable ventricular assist device HeartWare (HeartWare International Inc., Framingham, MA) to support the systemic circulation in two adult patients with transposition of the great arteries (TGA). One had undergone the Senning procedure as a neonate; the other had congenitally corrected TGA and dextrocardia with palliation in adulthood. It is possible to implant the HeartWare pump into the morphological right ventricle with cannulation of either the diaphragmal surface or the free wall without additional changes in implantation technique and employing off-pump insertion.

Pancreatic cysts can, in rare cases, expand into the posterior mediastinum and may require surgical resection. We present the case of a patient with a thoracic aneurysm, in whom the mediastinal involvement of a chronic pancreatic cyst masqueraded as a ruptured aneurysm. Surgery was undertaken: first, the initial resection and drainage of the thoracic portion of the pseudocyst, and second, a thorough cleansing of the entire cyst through median laparotomy 15 days later.

Right ventricular (RV) support in the case of RV failure after left ventricular assist device (LVAD) implantation is a well-established surgical therapeutic option. However, there is a serious limitation of RV support after the insertion of a LVAD through lateral thoracotomy in patients who have undergone previous multiple cardiac operations. We describe a modified surgical approach for implantation of right ventricular assist devices (RVADs) vialeft lateral thoracotomy, with venous cannulation viaa femoral vein and transpericardial outflow cannulation of the main pulmonary artery by Seldinger technique under echocardiographic monitoring. This technique was successfully used in a case with subsequent weaning from the RVAD after 10 days of support.

We present a case in which a left ventricular assist device (LVAD) was implanted in a patient with terminal heart failure and preoperatively diagnosed asymptomatic thrombus in the right pulmonary artery. LVAD implantation was performed with concomitant thromboembolectomy in deep hypothermic circulatory arrest (DHCA) and intra-operatively right ventricular assist device (RVAD) implantation for the treatment of acute right ventricular failure became necessary. The patient was weaned from the RVAD after eight days of support.