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Left ventricular assist devices (LVAD) have been increasingly used in the treatment of end-stage heart failure. While warfarin has been uniformly recommended in the long-term as anticoagulation strategy, no clear recommendation exists for the post-operative period. We sought to evaluate the feasibility of enoxaparin in the immediate and early postoperative period after LVAD implantation.This is a two-center, retrospective analysis of 250 consecutive patients undergoing LVAD implantation between January 2017 and December 2018. Patients were bridged postoperatively to therapeutic INR by either receiving unfractionated heparin (UFH) or low molecular weight heparin (LMWH). Patients were followed while inpatient and for 3 months after LVAD implantation. The efficacy outcome was occurrence of first and subsequent cerebrovascular accident while safety outcome was the occurrence of bleeding events. Length of stay (LOS) was also assessed.Two hundred fifty and 246 patients were analyzed for index admission and 3-month follow up respectively. No statistically significant differences were found between the two groups in CVA (OR = 0.67; CI = 0.07-6.39, P = 0.73) or bleeding events (OR = 0.91; CI = 0.27-3.04, P = 0.88) during index admission. Similarly, there were no differences at 3 months in either CVAs or bleeding events (OR = 0.85; 0.31-2.34; p = 0.76). No fatal events occurred during the study follow-up period. Median LOS was significantly lower (4 days; p = 0.03) in the LMWH group.LMWH in the immediate and early postoperative period after LVAD implantation appears to be a concurrently safe and efficacious option allowing earlier postoperative discharge and avoidance of recurrent hospitalizations due to sub-therapeutic INR.

Background Left ventricular assist devices (LVAD) have been increasingly used in the treatment of end-stage heart failure. While warfarin has been uniformly recommended in the long-term as anticoagulation strategy, no clear recommendation exists for the post-operative period. We sought to evaluate the feasibility of enoxaparin in the immediate and early postoperative period after LVAD implantation. Methods This is a two-center, retrospective analysis of 250 consecutive patients undergoing LVAD implantation between January 2017 and December 2018. Patients were bridged postoperatively to therapeutic INR by either receiving unfractionated heparin (UFH) or low molecular weight heparin (LMWH). Patients were followed while inpatient and for 3 months after LVAD implantation. The efficacy outcome was occurrence of first and subsequent cerebrovascular accident while safety outcome was the occurrence of bleeding events. Length of stay (LOS) was also assessed. Results Two hundred fifty and 246 patients were analyzed for index admission and 3-month follow up respectively. No statistically significant differences were found between the two groups in CVA (OR = 0.67; CI = 0.07–6.39, P = 0.73) or bleeding events (OR = 0.91; CI = 0.27–3.04, P = 0.88) during index admission. Similarly, there were no differences at 3 months in either CVAs or bleeding events (OR = 0.85; 0.31–2.34; p = 0.76). No fatal events occurred during the study follow-up period. Median LOS was significantly lower (4 days; p = 0.03) in the LMWH group. Conclusions LMWH in the immediate and early postoperative period after LVAD implantation appears to be a concurrently safe and efficacious option allowing earlier postoperative discharge and avoidance of recurrent hospitalizations due to sub-therapeutic INR.

Background The increasing prevalence of heart failure has led to the expanded use of left ventricle assist devices (VADs) for end-stage heart failure patients worldwide. Technological improvements witnessed the development of miniaturized VADs and their implantation through less traumatic "non-full sternotomy approaches" using a lateral thoracotomy (LT). Although adoption of the LT approach is steadily growing, there remains a lack of consensus regarding patient selection, details of the surgical technique, and perioperative management. Furthermore, the current literature does not offer prospective randomized studies or evidence-based guidelines for LT-VAD implantation. Methods A worldwide group of LT-VAD experts was convened to openly discuss these key topics. After a PubMed search and review with all authors, a consensus was reached and an expert consensus paper on LT-VAD implantation was developed. Results This document aims to guide clinicians in the selection of patients suitable for LT approaches and preoperative optimization. Details of operative techniques are described, with an overview of hemisternotomy and bilateral thoracotomy approaches. A review of the best surgical practices for placement of the pump, inflow cannula and outflow graft provides advice on the best surgical strategies to avoid device malpositioning while optimizing VAD function. Experts´ opinions on cardiopulmonary bypass, postoperative management, and approaches for pump exchange and explant are presented. This paper also emphasizes the critical need for multidisciplinary teams and specified training. Conclusions This expert consensus paper provides a compact guide to LT for VAD implantation, from patient selection through intraoperative tips and postoperative management.

Patient: Female, 67 Final Diagnosis: Pulmonary artery rupture Symptoms: Hemoptysis • shortness of breath Medication: — Clinical Procedure: Ventricular assist device Specialty: Cardiac Surgery Objective: Unusual clinical course Background: Pulmonary artery rupture can be a lethal complication of a pulmonary artery catheter (PAC). Different techniques have been used to manage PAC-induced pulmonary artery rupture, including double lumen endotracheal tube (DLT), bronchial blockers, pulmonary artery embolization, thoracotomy with hematoma evacuation, and extracorporeal life support for ventilation (ECLS). Single lumen endotracheal tube (ETT) is not frequently reported in the literature despite its advantages. Case Report: The authors present a case of PAC-induced pulmonary artery rupture successfully managed with a single lumen ETT. Although single lumen ETT is more labor intensive and requires constant critical care attention, the advantages of this technique are reported in this case in comparison to other well-documented therapies. Conclusions: With on-going pulmonary bleeding, a single lumen ETT intubation offers advantages to the commonly advocated methods of treating a PAC-induced pulmonary artery rupture.

Graphical abstract, Highlights • Traumatic RV pseudoaneurysm is a rare diagnosis. • Optimal management of RV pseudoaneurysm remains unknown. • The authors describe a novel percutaneous treatment approach for RV pseudoaneurysm.

Introduction: Tricuspid valve (TV) regurgitation is the most common valvular pathology after orthotopic heart transplant (OHT). The number of transplants being performed is increasing with patients living longer after heart transplant. Data on TV surgery in OHT recipients is limited. Methods: We sought to analyze the outcomes of patients undergoing TV surgery from a large diverse, multicentric, nationwide cohort using the Nationwide Inpatient Sample (NIS) database. Results:A total of 42,766 TV repair or replacement (bioprosthetic and mechanical) involving adult patients (age ≥18 years) between 2007 and September 2015 were identified. Of these, 366 were performed in patients with OHT. TV repair was the most common surgery performed in both groups (OHT group and native heart group). Compared to the native group, patients with OHT had a significantly higher incidence of cardiogenic shock (20 vs. 11%, p = 0.024), acute kidney injury (AKI) (59 vs. 30%, p < 0.001), and AKI requiring hemodialysis (13 vs. 4%, p < 0.001). Also, the mean length of stay for the index admission was significantly longer in the OHT group (27 vs. 17 days, p = 0.008). The mortality rate was similar between the two groups (7 vs. 8%, p = 0.753). The number of TV surgeries performed in OHT patients from 2007 to 2014 have remained stable (p = 0.803) compared to those in native heart patients which showed a significantly increasing trend (p = 0.019) during the same time period. Conclusions: TV surgery remains an important treatment modality among the OHT population and carries a similar mortality during index hospitalization as that in native heart patients undergoing TV surgery.

ObjectivesMultiple techniques have been used to repair degenerative mitral valve prolapse with leaflet elongation, without creating systolic anterior motion. We describe a simple, reproducible, measured technique to guide repair.MethodsFrom January 2010 to July 2012, 171 patients underwent mitral valve repair; 128 (75%) with Carpentier type II prolapse. For 48 patients (37.5%), the resected posterior leaflet free edge was partially folded to restore the normal 2:1 ratio of the A2 and P2. All patients underwent complete ring annuloplasty sized to the height of A2.ResultsThe preoperative A2/P2 ratio was 1.5 ± 0.5. After repair, the A2/P2 ratio was 1.9 ± 0.3 and 2.0 ± 0.3 in the no fold and partial fold groups, respectively (P = .57). The ring sizes were larger in the partial fold group (P

Severe symptomatic aortic stenosis (AS) is associated with high mortality without intervention. The impact of waiting time for aortic valve replacement (AVR), either surgically or transcatheter, has not been reported.From January 2008 to December 2012, we identified 1,005 patients with severe symptomatic AS. AVR was recommended for 823 patients (82%). Of these 823 patients, 721 (87.6%) underwent AVR. We modeled overall survival (OS) since AVR recommendation or intervention date using Cox and multistate models.Overall, the median (first, third quartiles) waiting time until operation was 2.9 (1.3, 5.1) weeks. Mortality at these times was lower (p0.001) in the AVR group (1.2%, 0.3%, 1.7%, respectively) than in the group that did not receive AVR (6.9%, 2.9%, 9.8%, respectively). Thirty-day mortality after AVR was 3.9% (3.2% surgical AVR [SAVR] and 7.0% transcatheter AVR [TAVR]). In patients receiving AVR, waiting time was not associated with increased mortality. Mortality while waiting for AVR was 3.7% and 11.6% at 1 and 6 months, respectively. Mortality while waiting for TAVR was higher than that for SAVR (1-, 6-, and 12-month mortality of 3.7%, 8.0%, and 9.6%, respectively, in SAVR group and 3.8%, 23.3%, and 27.5%, respectively, in TAVR group; p0.001).Some patients do not receive AVR in a timely fashion, and prolonged waiting time for AVR is associated with mortality greater than the AVR operative mortality. Although waiting time was not associated with poor operative outcomes after AVR, many patients may die while waiting for AVR. Patients should receive AVR on a semiurgent, not elective, basis.

Evaluate safety and efficacy of enoxaparin for bridging sub-therapeutic INR in first 3 months of discharge after LVAD implantation. All patients who received LVAD at our institution were followed for period of 3 months after discharge or study end date whichever came earlier. Total duration on

We set out to perform resection of a chest wall mass with subsequent reconstruction using a pure thoracoscopic approach. Using video-assisted thoracic surgery via a three-incision approach, we successfully removed an 8.5 × 3.5–cm specimen en bloc. We then reconstructed the chest wall with 2-mm polytetrafluoroethylene. A total thoracoscopic approach to chest wall resection and reconstruction represent an additional option in this area of thoracic surgery. This approach avoids some of the drawbacks of more invasive procedures. This report outlines a totally thoracoscopic approach that we feel represents a safe and viable option for patients requiring chest wall resection and reconstruction.

Infection of artificial joint replacements and heart valves is an uncommon but serious complication encountered anytime after the implantation of these prostheses. It is known that bacteremia can lead to infection of a prosthetic device. However, there is no strong evidence to correlate urologic procedures with the development of periprosthetic joint infection or prosthetic valve endocarditis. Therefore, antibiotic prophylaxis for the prevention of endocarditis is not recommended in patients undergoing urologic procedures. However, guidelines regarding prophylaxis to prevent infection of an artificial joint in the setting of a genitourinary procedure are more varied.

Postsurgical late reinterventions for atrial fibrillation (AF) include cardioversions (CV) or catheter ablations (CA). Commonly used methods for reporting and modeling the frequency and timing of CA or CV have well-known shortcomings.The purpose of this study was to present intuitive and robust methods to visualize, summarize, and model late reinterventions type/timing and vital status simultaneously.We present (1) the SMART plot (Summary of Mortality And Outcomes Reported Over Time); (2) the reintervention mean cumulative function (MCF); and (3) the proportional means model and the proportional rates model. We illustrate these methods in 3 groups: patients age ≤60 years, 60-75 years (reference), and75 years who underwent surgical AF ablation.Patients age75 years had a significantly lower MCF of CVs (hazard ratio [HR] 0.50, P.001). MCF for CAs was not significantly lower for patients age75 years (HR 0.57, P = .13). For combined reinterventions (CV or CA), the age group75 years had a significantly lower MCF (HR 0.51, P.001). There were no significant differences in late CV or CA reintervention patterns for patients age ≤60 years.The methods presented provide a comprehensive framework for displaying, summarizing, and modeling repeated late reinterventions after surgical AF ablation. Other areas of application are described, further emphasizing the potential for immediate use.

Left ventricular assist device (LVAD) infections continue to present a serious challenge in both the destination therapy and the bridge to transplant patient populations. As devices are supporting patients longer due to increased durability, infections can evolve and worsen over time. Complex infections, resistant to standard pharmacologic management, require a more aggressive approach to treatment. A series of patients supported by HeartMate II (HMII) LVADs, treated for multidrug resistant complex driveline infections, failed antibiotic therapy and then underwent device exchange. In each case, the HMII device was exchanged for a HeartWare HVAD as we felt its small size and flexible driveline were advantageous properties when dealing with patients with a complex driveline or pump infection.

BACKGROUND Distal intestinal obstructive syndrome (DIOS) is the partial or complete obstruction of the colon or the terminal ileum by abnormally viscous intestinal contents and is a common sequela of cystic fibrosis (CF) in adults. Medical management of this entity is well described, but often falls short for those with signs of peritonitis or bowel ischemia. Current surgical options are not widely reported. These procedures usually require laparotomy, occasionally with enterotomy, and are complicated by the typically poor medical condition of patients with DIOS. A minimally invasive approach to the surgical care of CF patients with DIOS could effectively relieve obstruction refractory to medical management. METHODS A 39-year-old woman with CF presented with nausea, severe abdominal pain, and obstipation. She was diagnosed with DIOS and underwent aggressive medical management unsuccessfully. The patient underwent successful hand-assisted laparoscopic antegrade milking of a 15-cm obstructive segment of the small bowel into the colon and placement of an appendicostomy tube. This was followed by postoperative administration of antegrade enemas and nasogastric osmotic cathartics. RESULTS The patient had resumption of bowel function and was subsequently discharged to her home. CONCLUSIONS This is a reported case of laparoscopic exploration and treatment for DIOS, and provides a minimally invasive alternative to laparotomy and enterotomy in the treatment of DIOS.

Echocardiographic markers of left ventricular unloading using a centrifugal-flow rotary pump Andrew J. Sauer, MD, Karen Meehan, ACNS-BC, Robert Gordon, MD, Travis Abicht, MD, Jonathan D. Rich, MD, Allen S. Anderson, MD, Clyde Yancy, MD, and Edwin C. McGee Jr, MD University Feinberg School of Medici Review Board. Once all baseline echocardiographic recorded, the speed was decreased every revolutions per minute (rpm) until the spee 2,200 to 2,400 rpm, which is the init determined by the speed that allowed f

Objective Paravalvular regurgitation is a known complication after transcatheter and sutureless aortic valve replacement. Paravalvular regurgitation also may develop in patients undergoing percutaneous mitral valve replacement. There are few studies on contemporary surgical valve replacement for comparison. We sought to determine the contemporary occurrence of paravalvular regurgitation after conventional surgical valve replacement. Methods We performed a single-center retrospective database review involving 1774 patients who underwent valve replacement surgery from April 2004 to December 2012: aortic in 1244, mitral in 386, and combined aortic and mitral in 144. Follow-up echocardiography was performed in 73% of patients. Patients with endocarditis were analyzed separately from noninfectious paravalvular leaks. Statistical comparisons were performed to determine differences in paravalvular regurgitation incidence and survival. Results During follow-up, 1+ or greater (mild or more) paravalvular regurgitation occurred in 2.2% of aortic cases and 2.9% of mitral cases. There was 2+ or greater (moderate or more) paravalvular regurgitation in 0.9% of aortic and 2.2% of mitral cases ( P = .10). After excluding endocarditis, late noninfectious regurgitation 2+ or greater was detected in 0.5% of aortic and 0.4% of mitral cases ( P = .93); there were no reoperations or percutaneous closures for noninfectious paravalvular regurgitation. Conclusions In an academic medical center, the overall rate of paravalvular regurgitation is low, and late clinically significant noninfectious paravalvular regurgitation is rare. The benchmark for paravalvular regurgitation after conventional valve replacement is high and should be considered when evaluating patients for transcatheter or sutureless valve replacement.

2.48-68.39, p= 0.024). A significant decrease in mean anti-CMV titers (baseline vs. day 30) was observed in both groups (CMV disease: 20419±14483 vs. 14235±11963, p= 0.044; no-CMV disease: 23232±2134 vs. 18247±1747, p< 0.001). There were no significative differences in mean specific anti-CMV titers between both groups in the analyzed study points. Conclusion: In conclusion, CMV-seropositive heart transplant recipients at risk for CMV disease can be identified based on readily assessable immunological biomarkers. Preventive strategies may be selectively targeted toward these patients.