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The Journal of Thoracic and Cardiovascular Surgery • Volume 122, Number 5 1043 R ight-side heart dysfunction after left ventricular assist device (LVAD) implantation is a feared complication and is responsible for a substantial amount of postoperative morbidity and mortality. In addition to preoperatively existing right ventricular impairment, intraoperative damage caused by ischemia, volume overload, and increased pulmonary vascular resistance may all worsen the situation. Most recently, Adamson and colleagues1 presented a technique of right-sided heart reperfusion, which we have used on the basis of their suggestions for more than 2 years.2 This technique consists of transferring the aortic cannula to the pulmonary artery after the LVAD begins to support the left ventricle and cardiopulmonary bypass (CPB) has been reduced to 2 L/min flow. The heart-lung machine then provides right ventricular support, and oxygenated blood is infused into the pulmonary circulation. The procedure, however, carries the risk of a somewhat abrupt cessation of CPB support with hemodynamic depression and the potential of right ventricular overload between the time of removal of the aortic cannula until CPB through the pulmonary artery has been resumed. Therefore, we have recently modified the procedure. Now, at the beginning of the implantation, a 24F aortic cannula is placed in the usual fashion into the ascending aorta and connected to the arterial line. A second 24F cannula is inserted into the pulmonary trunk and connected to the vent suction. The arterial line and vent suction lines are connected with additional tubing by means of Y connectors. This line is clamped during implantation (Figure 1, A and B). The LVAD is implanted with the heart beating, while blood is drained through the vent line connected to the pulmonary artery. After completion of the implant procedure, suction is halted, and the device is carefully deaired. When the LVAD is started and CPB flow can be reduced to 2 L/min, both the aortic cannula and the vent line are clamped, the connecting line is opened, and right-sided heart reperfusion is initiated (Figure 1, C). In this setting the left ventricle is supported by the LVAD, and the CPB supports the right ventricle.

A heparin induced thrombocytopenia Type II (HIT) is a dangerous complication of heparin therapy. Bleeding, but above all serious thromboembolic complications, which may result in crippling disabilities or even death, can develop. Twelve heart surgery patients who were diagnosed with a HIT Type II are reported. Seven of the patients were diagnosed post operatively, the other five pre-operatively. Two of these patients underwent heart surgery with r-Hirudin (Behringwerke AG, Marburg, Germany) on cardiopulmonary bypass and two on Orgaran (AKZO Organon, the Netherlands). Of the seven post operative HIT patients, four had had a bypass operation and each had received a mitral or aortic valve replacement. Another patient had received an artificial biventricular support system (Berlin Heart) and was diagnosed with HIT Type II post operatively. Because of his special condition, this patient underwent anticoagulation with Orgaran and heart transplantation with Orgaran on a heart lung machine. Upon suspicion of HIT Type II, heparin therapy was immediately halted and an alternative treatment of Orgaran or r-Hirudin was begun. One patient encountered bleeding of a gastric ulcer on Orgaran therapy. Heart surgery patients, especially patients with an artificial support system, are potentially lethally threatened by serious thromboembolic complications accompanying HIT Type II. Therefore, these patients must be diagnosed as early as possible. Orgaran along with r-Hirudin are effective heparin substitutes in patients with HIT Type II. These medications can be widely administered to heart surgery patients pre-, intra-, and post operatively without complication.

BACKGROUND: Hemodynamics assessment is important for detecting and treating post-implant residual heart failure, but its accuracy is unverified in patients with continuous-flow left ventricular assist devices (CF-LVADs).OBJECTIVES: We determined whether Doppler and 2-dimensional transthoracic echocardiography reliably assess hemodynamics in patients supported with CF-LVADs.METHODS: Simultaneous echocardiography and right heart catheterization were prospectively performed in 50 consecutive patients supported by using the HeartMate II CF-LVAD at baseline pump speeds. The first 40 patients were assessed to determine the accuracy of Doppler and 2-dimensional echocardiography parameters to estimate hemodynamics and to derive a diagnostic algorithm for discrimination between mean pulmonary capillary wedge pressure ≤15 versus >15 mm Hg. Ten patients served as a validation cohort.RESULTS: Doppler echocardiographic and invasive measures of mean right atrial pressure (RAP) (r = 0.863; p < 0.0001), systolic pulmonary artery pressure (sPAP) (r=0.880; p2, RAP >10 mm Hg, sPAP >40 mm Hg, left atrial volume index >33 ml/m2, ratio of mitral inflow early diastolic filling peak velocity to early diastolic mitral annular velocity >14, and pulmonary vascular resistance >2.5 Wood units, accurately identified patients with pulmonary capillary wedge pressure >15 mm Hg (area under the curve: 0.73 to 0.98). An algorithm integrating mitral inflow velocities, RAP, sPAP, and left atrial volume index was90%accurate in distinguishing normal from elevated left ventricular filling pressures.CONCLUSIONS: Doppler echocardiography accurately estimated intracardiac hemodynamics in these patients supported with CF-LVAD. Our algorithm reliably distinguished normal from elevated left ventricular filling pressures. © 2014 by the American College of Cardiology Foundation.

Background Topical hemostatic agents are used to reduce bleeding and transfusion need during cardiothoracic surgery. We report our experience with Arista® AH Absorbable Hemostatic Particles (Arista® AH), a novel plant-based microporous polysaccharide hemostatic powder. Methods Data were retrospectively collected for patients (n = 240) that received cardiothoracic surgery at our institution from January 2009 to January 2013 with (n = 103) or without (n = 137) the use of Arista® AH. Endpoints included protamine to skin closure time (hemostasis time), cardiopulmonary bypass time, quantity of Arista® AH applied, intraoperative blood product usage, intraoperative blood loss, chest tube output 48 hours postoperatively, blood products required 48 hours postoperatively, length of stay in the intensive care unit, 30-day morbidity, and 30-day mortality. Results 240 patients (176 M: 64 F) underwent 240 cardiothoracic procedures including heart transplantation (n = 53), cardiac assist devices (n = 113), coronary artery bypass grafts (n = 20), valve procedures (n = 19), lung transplantation (n = 17), aortic dissection (n = 8), and other (n = 10). Application of Arista® AH led to significant reduction in hemostasis time versus the untreated control group (Arista® AH: 93.4 ± 41 min. vs. Control: 107.6 ± 56 min., p = 0.02). Postoperative chest tube output in the first 48 hours was also significantly reduced (Arista® AH: 1594 ± 949 mL vs. Control: 2112 ± 1437 mL, p

Better understanding of hemodynamic alterations caused by long-term use of continuous-flow left ventricular assist devices (LVAD) is necessary to evaluate their impact onto the native heart and major vessels. In particular, aortic insufficiency is a known complication after LVAD implantation and may be related to alteration of pressure distribution on the leaflets of the aortic valve.