Search

We present the successful use of surgical embolectomy (SE) without systemic anticoagulation to treat a complicated case of pulmonary embolism. The patient presented with an embolic cerebrovascular accident and subsequently developed a massive pulmonary embolism. Because of the risk of hemorrhagic transformation, the decision was made to proceed with emergent SE on venoarterial extracorporeal membrane oxygenation support without anticoagulation. The surgery was performed without complication. The potential to perform SE without anticoagulation could potentially decrease the incidence of surgical bleeding and make SE a therapeutic option for patients with contraindications to anticoagulation. Further research is needed to substantiate the efficacy of this treatment strategy.

Left ventricular assist device (LVAD) implantation via a complete sternal-sparing (CSS) technique is gaining interest due to several potential benefits. We hypothesized that the CSS approach for HeartMate 3 (HM3) LVAD implantation improves postoperative mobility and physical independence compared to full sternotomy (FS). We retrospectively reviewed patients who were implanted with a commercial HM3 at our institution from September 2017 to August 2018. The Activity Measure for Post-Acute Care short forms and Functional Independence Measure scores were used to assess the patient’s physical limitations postoperatively. A total of 43 patients were included in the study: 27 (63%) CSS patients and 16 (37%) FS patients. At postoperative day 3, the CSS cohort demonstrated improved mobility based on Activity Measure for Post-Acute Care scores compared to the FS group; 40% of the CSS cohort versus 67% of the FS cohort remained 100% impaired. The CSS cohort also demonstrated greater postoperative independence in the Functional Independence Measure sit-to-stand metric with 78% of the CSS cohort achieving modified or complete independence by postoperative day 15 compared to only 21% of the FS patients. These early data suggest that the CSS approach for HM3 LVAD implantation improves postoperative mobility and functional independence compared to FS.

Purpose We sought to develop and implement a comprehensive enhanced recovery after surgery protocol for patients implanted with left ventricular assist device. Methods Our approach to the development and phased implementation of the ERAS protocol were described (Figure 1). We retrospectively reviewed prospectively collected LVAD implant data at our institution between February 2019 and August 2020. Patients were divided into 6-months period cohorts: Pre-ERAS cohort (which covered 6 months prior to ERAS initiation) and ERAS cohort. A time gap of 6 months between the cohorts was used to appreciate initial outcomes after implementing most of the protocol phases. Results Of the 115 LVAD implants, 38 patients were classified in pre-ERAS cohort and 46 in ERAS cohort. We reduced transfusions and discharge on opioids and show a trend towards reduced intubation times, ICU and overall length of stay (Table 1). Conclusion ERAS for advanced heart failure patients deemed candidates for LVAD therapy is a novel, evidence-based, interdisciplinary approach to care with multiple potential benefits. We described details of the protocol, challenges faced as well as early positive changes in clinical outcomes. Further studies are needed to both assess provider satisfaction and evaluate benefits of an ERAS protocol in reduction of adverse events.

We present a complicated case of massive pulmonary embolism occurring 11 weeks after a craniotomy in a patient with multiple high-risk comorbidities. The patient underwent successful pulmonary artery surgical embolectomy via left mini-thoracotomy incision on peripheral venoarterial extracorporeal membrane oxygenation support. For this patient, avoiding a sternotomy allowed for greatly decreased postoperative morbidity and the use of venoarterial extracorporeal membrane oxygenation allowed for the avoidance of intraoperative anticoagulation. This case demonstrates the feasibility of off-pump surgical pulmonary embolectomy via left mini-thoracotomy as a treatment strategy for appropriate patients to improve patient-centred care.

Purpose The purpose of the present study is to examine the effect of operative time of day on outcomes in orthotopic heart transplant (OHT) recipients. We hypothesized that nighttime OHT operations would be associated with increased 1-year mortality when compared to daytime OHT operations. Methods We performed a retrospective analysis of adult heart transplant recipients in the United Network for Organ Sharing (UNOS) database from January 2000 to December 2019. Operative time of day was derived from the donor cross-clamp time (night, 6 pm-4 am; day, 4 am-6 pm). The primary outcome was survival at 1 year. Kaplan-Meier curves and log-rank statistics were generated to compare the effect of operative time and were further stratified by age, transplant center yearly volume (low volume, Results Of the 42,007 patients included in the study, 24,200 (57.6%) underwent nighttime and 17,807 (42.4%) daytime OHT (Table 1). Preoperative patient characteristics were similar between cohorts. 1-year survival (Figures 1) was not different between the cohorts (89.7 vs 89.5%, p=0.630). When further stratified by age, center volume, or VAD status, 1-year survival between operative times still remained insignificant. Conclusion There is no significant association between nighttime operations and 1-year post-transplant survival in adult heart transplant recipients.