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A young man presented with a chronic abdominal dermal irritation 4 years after implantation of a left ventricular assist device (LVAD; Berlin heart excor). The LVAD was needed because of end-stage heart failure following a chronic parvovirus B19 Infection. The implantation of mechanical circulatory support systems (MCS) has nowadays become an accepted treatment modality for patients with end-stage heart failure. Recent literature shows several intestinal complications related to MCS, but no case presents the development of a small bowel fistula to the jejunum, transversal colon and stomach. We present a case of inaccurate placement of Berlin heart excor LVAD cannulas and its impact. This case emphasises the importance of correct placement of VAD cannulas to achieve an optimal long-term result. After surgical treatment the postoperative course was prolonged because of increasing peritonitis probably based on ongoing intraperitoneal chronic contamination with intestinal germs. The patient unfortunately deceased.

treated for bronchitis or pneumonia and one for an invasive anastomotic fungal infection with Candida albicans. No patient developed CMV pneumonia. All subjects had normal renal function throughout the post-transplant course (mean creatinine 1.0 0.3mg/dL). The average tacrolimus level within 3 months post transplantation was 10.5 1.6ng/mL. T cell characteristics within 7 days post-transplant were on average; CD3 26.4 10/mcL (nl 700-2700), CD4 14.6 9/mcL (425-2000) and CD19 2.9/mcL 2.2 (120-520). Conclusions: Campath successfully reduces the need for systemic immunosuppression early after transplantation. The average rejection rate was acceptable on a low level maintenance immunosuppressive regimen.

Mechanical Circulatory Support for the Treatment of Cardiogenic Shock in Children and Adolescents with Acute Fulminant Myocarditis S. Buz, Y. Weng, M. Huebler, T. Drews, C. Knosalla, H. Lehmkuhl, M. Dandel, F. Berger, R. Hetzer, Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany; Department of Congenital Heart Defects/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany

Patients with Mechanical Circulatory Support (MCSD): Is Implant Strategy Static or Dynamic? M. Jessup, L. Warner Stevenson, P. Desvigne-Nickens, J. Young, M. Acker, C. Milano, S. Wissman, O.H. Frazier, D.C. Naftel, J.K. Kirklin, Hospital of the University of Pennsylvania, Philadelphia, PA; Brigham and Women’s Hospital, Boston, MA; NHLBI, Washington, DC; Cleveland Clinic, Cleveland, OH; Duke University Medical Center, Durham, NC; Ohio State University Medical Center, Columbus, OH; Texas Heart Institute, Houston, TX; University of Alabama at Birmingham, Birmingham, AL

Since the earliest applications of LVADs, it has always been a goal to obtain a totally wear-free system. INCOR, an axial flow pump for left-heart support, has a virtually unlimited life due to magnetic suspension of the rotating impeller. A control algorithm avoids sucking-in of myocardial tissue and therefore all side effects such as profound arrhythmia. In-pump sensors allow flow adaptation to the patient’s needs. Out of 72 patients supported by the device since June 2002, 31 (1f, 30m; mean age 53, range 36-65 years) with end-stage heart failure received the system at this institute. Anticoagulation consisted of postoperative administration of heparin and of Aspirin, clopidogrel, and Warfarin later on. For dosage adjustment, INR, thrombelastography and platelet aggregometry were performed. Anti-heart-failure medication was administered. A variety of blood chemistry examinations were performed to check for hemolysis. The mean follow-up period is 127 days (range, 12-454); 19 patients are still being supported. It was possible to wean two of the patients because of cardiac improvement after 178 and 206 days, respectively. Two patients received transplants and 8 died due to multi-organ failure after a mean of 49 (range 22-126) days. Three patients showed signs of a TIA and two had cerebral bleeding. Due to the anti-suction algorithm, suction of myocardium with subsequent arrhythmia could not be detected. After 2 months, blood chemistry showed normal values for all organ functions, in particular no hemolysis and no deviations of any blood cell count were observed. None of the patients showed signs of infection (CRP normal). According to the information gained from the in-pump sonsors, an adjustment of the flow to meet the therapeutic goal and the patient’s needs was easily achieved. Application of up-to-date technology in the design of axial flow pumps significantly improves the clinical outcome. Especially the problems resulting from chronic systemic infection seem to have been solved. The in-pump sensor system enables optimization of the treatment.

Background: Left ventricular assist devices (LVADs) have demonstrated the ability to improve cardiac function to such an extent that 15% of our patients were ultimately weaned from LVAD instead of undergoing heart transplantation. However, predictive parameters have still not been found. Methods: In the serum of 6 patients with dilated cardiomyopathy circulating concentration of carboxy-terminal propeptide of type I collagen (PICP), amino-terminal propeptide of type I and III collagen (PINP, PIIINP), and type I collagen telopeptide (ICTP) were measured by a radioimmunoassay. Echocardiographic examinationwasundertaken at the time the serum sampleswere collected. Left ventricular ejection fraction (LVEF) and left ventricular end-diastolic dimension (LVIDd) were the functional parameters used in this study. Results: The changes in serum concentration showed that PIIINP increased constantly during LVAD support in those patients who could not be weaned (at implantation 0.99 0.26, at transplantation 6.9 2.4 micro g/ml). In contrast PICP (at implantation 170.9 70.9, at weaning 203.2 80.2 micro g/l) and PINP (at implantation 15.5 3.5, at weaning 50.9 22.9 micro g/l) increased in the group of patients who were successfully weaned. The concentration of PICP and PINP increased in early stages (2 months) of LVAD support in the serum of patients who could be weaned later on. PIIINP showed a linear increase over time in the serum of the later transplanted patients. A statistically significant correlation between the serum peptides and the cardiac function parameters was found for PICP and PINP. At the time of implantation there was no significant difference found between the peptide concentration in serum of patients whowere weaned and thosewho were not weaned. ICPT showed no significant differences between the two groups. Conclusions: The increase of PINP and PICP, representing collagen type I synthesis, may be a sign of reversion of maladaptive remodeling. However, the constant increase of PIIINP, representing collagen type III synthesis, may relate to poorer prognosis with regard to improvement of cardiac function.

Objectives The purpose of the present study was to test whether the cumulative knowledge from the field of transapical transcatheter aortic valve implantation, when incorporated into a structured training and then gradually dispersed by internal proctoring, might eliminate the negative effect of the learning curve on the clinical outcomes. Methods The present study was a retrospective, single-center, observational cohort study of prospectively collected data from all 500 consecutive high-risk patients undergoing transapical transcatheter aortic valve implantation at our institution from April 2008 to December 2011. Of the 500 patients, 28 were in cardiogenic shock. Differences during the study period in baseline characteristics, procedural and postprocedural variables, and survival were analyzed using different statistical methods, including cumulative sum charts. Results The overall 30-day mortality was 4.6% (95% confidence interval, 3.1%-6.8%) and was 4.0% (95% confidence interval, 2.6%-6.2%) for patients without cardiogenic shock. Throughout the study period, no significant change was seen in the 30-day mortality (Mann-Whitney U test, P = .23; logistic regression analysis, odds ratio, 0.83 per 100 patients; 95% confidence interval, 0.62-1.12; P = .23). Also, no difference was seen in survival when stratified by surgeon (30-day mortality, P = .92). An insignificant change was seen toward improved overall survival (hazard ratio, 0.90 per 100 patients; 95% confidence interval, 0.77-1.04; P = .15). Conclusions The structured training program can be used to introduce transapical transcatheter aortic valve implantation and then gradually dispersed by internal proctoring to other members of the team with no concomitant detriment to patients.