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ECMO is the most frequently used mechanical support for patients suffering from low cardiac output syndrome. Combining IABP with ECMO is believed to increase coronary artery blood flow, decrease high afterload, and restore systemic pulsatile flow conditions. This study evaluates that combined effect on coronary artery flow during various load conditions using an in vitro circuit. In doing so, different clinical scenarios were simulated, such as normal cardiac output and moderate-to-severe heart failure. In the heart failure scenarios, we used peripheral ECMO support to compensate for the lowered cardiac output value and reach a default normal value. The increase in coronary blood flow using the combined IABP-ECMO setup was more noticeable in low heart rate conditions. At baseline, intermediate and severe LV failure levels, adding IABP increased coronary mean flow by 16%, 7.5%, and 3.4% (HR 60 bpm) and by 6%, 4.5%, and 2.5% (HR 100 bpm) respectively. Based on our in vitro study results, combining ECMO and IABP in a heart failure setup further improves coronary blood flow. This effect was more pronounced at a lower heart rate and decreased with heart failure, which might positively impact recovery from cardiac failure.

Fulminant myocarditis (FM) is a severe disease with a rapidly progressive and life-threatening course caused mainly by viral infection. The symptoms, laboratory findings, and presence of ECG changes resemble acute coronary syndrome. Therefore, coronary angiography is usually helpful in making the appropriate diagnosis. However, failure to obtain complete coronary artery images due to coronary artery anatomic variations poses a challenge for the diagnosis of FM. Here, we report a case of FM preliminarily diagnosed as acute coronary syndrome (ACS) due to the presence of coronary artery anomaly.

Del Nido cardioplegia offers equivalent myocardial protection and clinical outcomes to blood cardioplegia in adult isolated CABG and valve patients, but the safety and efficacy of del Nido in complex cases with prolonged aortic cross-clamp times is still unknown. 443 patients at our center underwent replacement of the ascending aorta using either del Nido (n = 182) or blood (n = 261) cardioplegia. Two surgeons used del Nido exclusively and 6 used blood exclusively over the study period. Propensity matching of preoperative characteristics yielded 172 well matched pairs. Emergency and reoperative cases were included. Clinical data were extracted from our local database. Troponin levels were drawn at 12 hours postop in all patients. Rates of perioperative mortality (4.7% vs 5.2%), stroke (5.8% vs 7.0%), renal failure (11.6% vs 12.2%), atrial fibrillation (36.0% vs 31.4%), intra-aortic balloon pump insertion (2.3% vs1.2%), and extra corporeal membrane oxygenation use (4.7% vs 4.1%) did not differ between blood and del Nido groups. Postop Troponin T levels were 0.50[0.35, 0.86] ng/mL and 0.40[0.20, 0.70] ng/mL for blood and del Nido, respectively (P0.0001). Postop echocardiography was available in 333 of 344 (96.8%) patients, and there was no difference in change in EF from pre- to postop between blood 0.0[-6.0, 5.0]% and del Nido 0.0 [-6.0, 3.5]% (P = 0.201). Subgroup analysis of patients with aortic cross-clamp time greater than 180 minutes (blood = 77, del Nido = 27) revealed no difference in troponins, ejection fraction, or clinical outcomes. Five-year survival was 85.9[76.8, 91.7]% and 79.8[71.2, 86.1]% for blood and del Nido, respectively (P = 0.151). In ascending aortic surgery with prolonged operative times, no differences were observed in myocardial protection or clinical outcomes with the use of del Nido cardioplegia compared to blood cardioplegia.

Background Myocardial infarction complicated by cardiogenic shock (MI-CS) has a poor prognosis, even with early revascularisation. Previously, intra-aortic balloon pump (IABP) use was thought to improve outcomes, but the SHOCK-II trial in 2012 found no survival benefit. Purpose This study aimed to determine the trends in IABP use in patients with MI-CS undergoing percutaneous intervention (PCI) over time and characteristics associated with use. Methods Between 2005–2018, patients presenting with MI-CS that underwent percutaneous coronary intervention (PCI) at a hospital participating in the Melbourne Interventional Group Registry were included. The primary outcome was the trend in IABP use over time. Secondary outcomes included mortality, 30-day MACCE (major adverse cardiovascular and cerebrovascular events) and predictors of outcome, determined via logistic regression. Results Of the 1,110 patients identified, IABP was used in 478 (43%). IABP was used more in patients with left main and left anterior descending culprit lesions (62% vs. 46%), lower ejection fraction ( Conclusions Consistent with the SHOCK II trial, IABP use is not associated with reduced short- or long-term mortality, but in this study was associated with increased short-term adverse events. IABP use is declining, but is still used in sicker patients with greater myocardium at risk, given limited alternatives. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Melbourne interventional group

INTRODUCTION Intra-aortic balloon pump (IABP) is a mechanical device that increases cardiac output by increasing diastolic blood flow to the coronary arteries and lowers the afterload of the left ventricle in systole. IABP is primarily used in acute heart failure, that includes patients that have to undergo coronary artery bypass grafting (CABG). Its usage, however, in cardiac surgery has been declining with ongoing controversy regarding its benefits. The aim of this study was to assess the use and indications and outcome of IABP related to CABG surgery. MATERIAL AND METHODS The study was retrospective and included 2177 patients that underwent CABG at Landspitali during 2001-2018. We compared those who received an IABP with controls, using uni- and multivariate analysis. Long term survival and complications (major adverse cardiovascular and cerebral events, MACCE) was estimated with Kaplan-Meier method. RESULTS A total of 99 (4.5%) patients received an IABP. The incidence was highest in 2006 (8.9%) and lowest in 2001 (1.7%), but the incidence did not change during the study period (p=0.90). Most patients received the pump before (58.6%) or during (34.3%) CABG, but only 6.1% after surgery. Complication rate was 14.1%, with bleeding from the insertion site in the groin being the most common complication. Thirty day mortality was higher in the IABP group compared with controls (22.2% vs 1.3%, p

Intra-aortic balloon pump via the axillary approach has been increasingly utilized to facilitate physical rehabilitation prior to definitive heart failure therapy. There is a high risk of device fracture with loss of arterial accessibility. Three cases are presented that demonstrate innovative arteriotomy hemostasis techniques for malfunctioning axillary intra-aortic balloon pumps. (Level of Difficulty: Intermediate.), Graphical abstract, Intra-aortic balloon pump via the axillary approach has been increasingly utilized to facilitate physical rehabilitation prior to definitive…

OBJECTIVES We studied the flow pattern in the superior mesenteric artery (SMA) during intra-aortic balloon pump support, comparing 2 intra-aortic balloons of 2 different lengths. METHODS Sixteen Landrace pigs (mean weight 84.0 kg ± 6.0) were used in this study. The animals were randomly assigned to 2 groups: group 1 received an 8-Fr, 40-ml standard balloon; group 2 received an 8-Fr, 40-ml short balloon. SMA flow was measured during early, mid- and telediastole. RESULTS The standard balloon led to a reduction in SMA flow in early diastole (P CONCLUSIONS Despite better overall mean mesenteric diastolic flow, the short balloon leads to early- and mid-diastolic flow reduction, although to a lesser extent than the standard intra-aortic balloon pump balloon. Our data are a call for improvement in the design of the short balloon.

Objectives: This study aimed to prospectively investigate intra-aortic balloon pump counterpulsation (IABP) support in large myocardial infarction complicated by persistent ischemia after primary percutaneous coronary intervention (PCI). Background: Use of IABP is suggested to be effective by increasing diastolic aortic pressure, thereby improving coronary blood flow. This can only be expected with exhausted coronary autoregulation, typical in acute myocardial infarction complicated by persistent ischemia. In this situation, augmented diastolic pressure is expected to increase myocardial oxygenation. Methods: One hundred patients with large STEMI complicated by persistent ischemia after primary PCI were randomized to treatment with or without IABP therapy on top of standard care. IABP support was initiated following primary PCI, immediately after inclusion. Primary end point was all-cause mortality, need for (additional) mechanical hemodynamic support, or readmission for heart failure within 6 months. Results: Mean age was 63 ± 10 years, 76% were male. Mean systolic and diastolic blood pressure were 120 ± 25 mmHg and 73 ± 17 mmHg. Mean heart rate was 75 ± 18 mmHg. Before PCI, mean summed ST-deviation was 21 ± 8 mm with only minimal ST-resolution after PCI. One patient in the IABP group reached the primary end point versus four patients in the control group (2% vs. 8%; p = 0.16). After primary PCI, resolution of ST-deviation was significantly more pronounced in the IABP group (73 ± 17%) compared to the control group (56 ± 26%; p < 0.01). Conclusions: In this pilot study, in patients with large STEMI and persistent ischemia after primary PCI, use of IABP showed a nonsignificant decrease in mortality, necessity for (additional) mechanical hemodynamic support or readmission for heart failure at 6 months, and resulted in more rapid ST-resolution.

There is little evidence to recommend the optimal invasive mechanical ventilation (IMV) modes and ideal positive end-expiratory pressure stress levels for acute myocardial infarction-cardiogenic shock (AMI-CS) patients. The aim of this study was to compare the mortality outcome in patients with AMI-CS who were treated with percutaneous coronary intervention (PCI) assisted by intra-aortic balloon pump (IABP) + IMV with historical controls. From January 1, 2016 to June 1, 2017, 60 patients were retrospectively enrolled at Tianjin Chest Hospital. Out of these, 88.3% of patients achieved thrombolysis in myocardial infarction (TIMI) flow 3 after PCI. The all-cause mortality rate in-hospital and at 1 year was 25% (95% CI: 0.14-0.36) and 33.9% (0.22-0.46), respectively. A systematic review followed by meta-analysis was performed with four historical studies of patients treated by PCI + IMV with partial IABP, which found an in-hospital mortality rate of 66.0% (95% CI: 0.62-0.71). Recently, a meta-analysis of patients receiving PCI + IABP with partial IMV showed that the 1 year mortality rate was 52.2% (95% CI: 0.47-0.58). In Cox regression analysis of patient data from the current study, lactic acid level ≥4.5 mmol/L, hyperuricemia, and TIMI flow

Objective: The objective of the study is to compare the immediate postoperative cardiac complications in patients undergoing off-pump coronary artery bypass grafting (OPCABG) using mixed (arterial and venous grafts) versus only venous grafts and to compare the requirement of packed red cell units and intra-aortic balloon pump (IABP) in both the groups. Materials and Methods: This was an observational, analytical, prospective study. Sample Size: Fifty new patients were included in the study. Inclusion/Exclusion Criteria: Patients diagnosed with triple-vessel coronary artery disease (CAD) undergoing OPCABG with an ejection fraction (EF) of more than 30%. Patients who have undergone prior CABG, EF

Background:Todefine acute kidney injury (AKI) that develops following coronary artery bypassgrafting (CABG) surgery using RIFLE classification system and to determine therisk factors affecting the early and late mortality of the patients whodeveloped acute kidney injury.Materials and Methods: Atotal of 213 patients who underwent isolated CABG operation in our clinicbetween February 2016 and September 2018 were retrospectively investigated.Preoperative and postoperative estimated glomerular filtration rates were calculatedfor all patients. The diagnosis and severity of AKI was determined by RIFLEclassification.Results: The median age ofthe patients included in the study was 62, of whom 114 were male. In thepostoperative period, AKI was detected in 65 (30.5%) patients according toRIFLE classification. 63.1 % of the patients were in stage R, 23.1 % were instage I, 13.8 % were in stage F. L and Estages of AKI did not develop in any patients. Comorbid conditions such as diabetesmellitus, hypertension, congestive heart failure and peripheral artery disease,and the duration of cardiopulmonary bypass (CPB) were detected to beindependent risk factors for the development of AKI. Bleeding revision need forhemodialysis, usage of intra aortic balloon pump and respiratory complicationswere higher in the AKI group than in the non-AKI group. In addition,in-hospital and long term mortality rates were significantly higher in AKIgroup. As the severity of AKI increased, the survival rates of the patientswere decreased. The patients in stage –F had the lowest survival rate.Conclusion: RIFLEclassification is a low-cost and easy-to-use tool to detect AKI developingafter CABG surgery and it helps to detect kidney injury at the initial stage.This classification provides a prediction about the mortality and morbidity ofthe patients who developed AKI following CABG surgery., Amaç: RIFLEsınıflamasını kullanarak Koroner arter bypass greftleme (KABG) cerrahisisonrasında gelişen akut böbrek hasarını (ABH) tanımlamak, hasar gelişmişhastaların erken ve geç dönem mortalitelerine etki eden risk faktörlerinibelirlemektir.Materyal ve Metod: KliniğimizdeŞubat 2016 ile Eylül 2018 yılları arasında izole KABG operasyonu yapılan 213hasta geriye dönük olarak incelendi. Tüm hastaların operasyon öncesi ve sonrasıtahmini glomeruler filtrasyon hızları hesaplandı. ABH’nin tanısı ve ciddiyeti,RIFLE sınıflaması ile belirlendi. Bulgular: Çalışmayadâhil edilen hastaların medyan yaşı 62 yıldı, hastaların 144’ü (%67,6)erkekti. Postoperatif dönemde, RIFLEsınıflamasına göre 65 (%30,5) hastada ABH saptandı. Hastaların %63,1’i evre R, %23,1’i evre I,%13,8’i ise F evresindeydi. ABH’nin L ve E evresi hiçbir hastada gelişmedi.Diyabetes mellitus, hipertansiyon, konjestif kalp yetmezliği, periferik arterhastalığı gibi komorbid faktörler ve kardiyopulmoner bypass (KPB) süresi ABHgelişiminde bağımsız risk faktörleri olarak saptandı. ABH bulunan grupta ABHbulunmayan gruba göre post operatif dönemde kanama revizyonu, hemodiyalizihtiyacı, intraaortik balon pompası kullanımı ve solunumsal komplikasyonlardaha fazlaydı. Ek olarak, hastane içi ve geç dönem mortalite oranları ABH olangrupta daha yüksekti. Hastaların sağkalım oranları ABH’nin ciddiyeti arttıkçadüştü. Evre F’deki hastalar en düşük sağkalım oranına sahipti.Sonuç: RIFLEsınıflaması, KABG cerrahisi sonrası gelişen ABH’yi gösteren maliyeti düşük vekolay uygulanabilir bir araçtır ve böbrek hasarının başlangıç evresindesaptanmasına yardımcı olur. Bu sınıflama, KABG cerrahisi sonrası ABH gelişenhastaların mortalite ve morbiditesi hakkında öngörü sağlar.

Patient: Female, 67-year-old Final Diagnosis: Heart failure Symptoms: Chest pain • dyspnoea • poor exercise tolerance Medication: — Clinical Procedure: Intraoartic baloon pump insertion – new technique Specialty: Cardiac surgery Objective: Management of emergency care Background: The use of an intra-aortic balloon pump (IABP) in patients with advanced heart failure can provide interim mechanical support as a bridge to further treatment, including cardiac transplantation. The femoral artery, axillary artery, and subclavian artery are the main approaches to IABP catheter placement. A case is reported of the use of a left external iliac artery approach to IABP catheter placement using a subcutaneous channel in a patient with chronic heart failure. Case Report: A 67-year-old woman presented with a history of heart failure. She had New York Heart Association (NYHA) Functional Class IV symptoms. The patient had a history of chronic heart failure due to dilated cardiomyopathy with a left ventricular ejection fraction of 25%, severe mitral regurgitation, paroxysmal atrial fibrillation, and hypothyroidism. Immediate pharmacological treatment began, and an IABP catheter was initially inserted using femoral artery access. During 115 days of hospital treatment, several unsuccessful attempts were made to remove the IABP catheter. Due to prolonged patient immobility, the IABP catheter access was changed from the femoral artery to the external iliac artery. A prosthetic Dacron graft and a subcutaneous channel were used. Optimal pharmacotherapy commenced, and the patient underwent rehabilitation and mobilization with significant improvement in cardiac function. At 195 days after changing the IABP catheter access, the patient underwent successful heart transplantation. Conclusions: This report demonstrated that in a patient with chronic heart failure requiring long-term femoral IABP catheter placement, an external iliac artery approach using a subcutaneous channel provided a bridge to cardiac transplantation.

Percutaneous coronary intervention (PCI) is establishing as the last remaining revascularization option in an increasing number of patients affected by complex coronary artery disease not suitable for surgery. Over the past decade, percutaneous left ventricular assist device (pLVAD) has increasingly replaced intra-aortic balloon pump to provide hemodynamic support during such non-emergent complex high-risk indicated procedures (CHIP) averting the risk of circulatory collapse and of adverse events in long lasting and/or complicated procedures. This review article aims to report the key factors to define CHIP, to summarize the available pLVAD which have CE mark for temporary mechanical LV support and to discuss the rationale of their use in this subset of patients. Based on the expertise of the Italian Society of Interventional Cardiology working group, with the endorsement from Spanish and Portuguese Society of Interventional Cardiology working groups, it will provide several practical suggestions in regards to the use of pLVAD in different clinical CHIP scenarios.

[Resumen] Introducción y objetivos. En España, el balón de contrapulsación intraaórtico (BCIA) se ha usado frecuentemente como puente al trasplante cardiaco (TxC) urgente. El propósito es analizar los resultados de esta estrategia. Métodos. Se realizó una revisión retrospectiva caso por caso de los registros clínicos de 281 pacientes adultos listados para TxC urgente asistidos con BCIA en 16 hospitales españoles entre 2010 y 2015. Se analizaron la supervivencia antes y después del trasplante y la incidencia de eventos adversos. Resultados. Se trasplantó a 194 pacientes (69%; IC95%, 63,3-74,4) y 20 (7,1%; IC95%, 4,4-10,8) fallecieron durante la asistencia, cuya duración media fue de 10,9 ± 9,7 días. El BCIA se explantó antes de obtener un órgano a 32 pacientes (11,4%). En 35 pacientes (12,5%; IC95%, 8,8-16,9) se implantó un dispositivo de asistencia circulatoria mecánica completa. El tiempo en la lista de espera urgente se incrementó desde 5,9 ± 6,3 días en 2010 hasta 15 ± 11,7 días en 2015 (p = 0,001). La supervivencia a 30 días y a 1 y 5 años tras el TxC fue del 88,1% (IC95%, 85,7-90,5), 76% (IC95%, 72,9-79,1) y 67,8% (IC95%, 63,7-71,9) respectivamente. La tasa de incidencia de eventos adversos mayores —disfunción del BCIA, ictus, hemorragia o infección— durante la asistencia fue de 26 (IC95%, 20,6-32,4) eventos/1.000 pacientes-día. La tasa de incidencia de explante del BCIA por complicaciones fue de 7,2 (IC95%, 4,5-10,8) casos/1.000 pacientes-día. Conclusiones. En el contexto de listas de espera cortas, el BCIA puede utilizarse como puente al TxC urgente con resultados aceptables. Esta estrategia conlleva una incidencia significativa de eventos adversos. [Abstract] Introduction and objectives. In Spain, intra-aortic balloon pump (IABP) has been used frequently as a bridge to urgent heart transplant (HT). We sought to analyze the clinical outcomes of this strategy. Methods. We conducted a case-by-case, retrospective review of clinical records of 281 adult patients listed for urgent HT under IABP support in 16 Spanish institutions from 2010 to 2015. Pre- and post-transplant survival and adverse clinical events were analyzed. Results. A total of 194 (69%, 95%CI, 63.3-74.4) patients were transplanted and 20 (7.1%, 95%CI, 4.4-10.8) died during a mean period of IABP support of 10.9 ± 9.7 days. IABP support was withdrawn before an organ became available in 32 (11.4%) patients. Thirty-five (12.5%, 95%CI, 8.8-16.9) patients transitioned from IABP to full-support mechanical devices. Mean urgent waiting list time increased from 5.9 ± 6.3 days in 2010 to 15 ± 11.7 days in 2015 (P = .001). Post-transplant survival rates at 30-days, 1-year, and 5-years were 88.1% (95%CI, 85.7-90.5), 76% (95%CI, 72.9-79.1), and 67.8% (95%CI, 63.7-71.9), respectively. The incidence rate of major adverse clinical outcomes—device dysfunction, stroke, bleeding or infection—during IABP support was 26 (95%CI, 20.6-32.4) episodes per 1000 patient-days. The incidence rate of IABP explantation due to complications was 7.2 (95%CI, 4.5-10.8) cases per 1000 patient-days. Conclusions. In a setting of short waiting list times, IABP can be used to bridge candidates to urgent HT with acceptable postoperative results, but there were significant rates of adverse clinical events during support.

We report the case of a 79-year-old man with acute myocardial infarction caused by left main trunk lesion, who experienced cardiogenic shock during percutaneous coronary intervention (PCI). To reverse the cardiogenic shock, we initiated veno-arterial extra corporeal membrane oxygenation (VA-ECMO) without an intra-aortic balloon pump (IABP) due to the severe tortuosity of the left external iliac artery. Although PCI was successful, arterial pressure monitoring revealed that the pulse pressure was too low to recover from the cardiogenic shock of decreased cardiac contraction function (the left ventricular ejection fraction was 30%). Thus, we decided to use IABP from the brachial artery to improve the hemodynamics. Immediately after the deployment of a 6-Fr IABP system (Takumi) from the left brachial artery, the pulse pressure was restored and finally VA-ECMO was withdrawn from the patient without complications. Although using IABP in combination with VA-ECMO is a reasonable strategy for cardiogenic shock, the effectiveness of this combination remains controversial. In this case, IABP added to VA-ECMO clearly achieved an improvement of pulse pressure and vital signs. Based on this result, monitoring of the pulse waveform is an effective tool to determine whether the concomitant use of IABP with VA-ECMO is indicated. Moreover, when it is difficult to insert IABP from the femoral arteries, the use of a 6-Fr IABP system (Takumi) approaching from the brachial artery should be considered.

International audience; PURPOSE OF REVIEW: Temporary circulatory support (TCS) with venoarterial extracorporeal membrane oxygenation (VA-ECMO) is increasingly used as a salvage therapy for patients with refractory cardiogenic shock. This article provides an overview of VA-ECMO principles, indications, management, complications, and discusses the results of recent case series and trials.RECENT FINDINGS: VA-ECMO is utilized as a bridge to 'decision' that includes weaning after cardiac function recovery, transplantation, long-term mechanical circulatory support, and withdrawal in case of futility. VA-ECMO is considered the first-line TCS as it allows rapid improvement in oxygenation, is less expensive, and is also suitable for patients with biventricular failure. Combining Impella (Abiomed, Danvers, MA, USA) or intra-aortic balloon pump support with VA-ECMO might decrease left ventricular pressure and improve outcomes. Massive pulmonary embolism, sepsis-associated cardiomyopathy, and refractory cardiac arrest are among emerging indications for TCS.SUMMARY: TCS have become the cornerstone of the management of patients with cardiogenic shock, although the evidence supporting their efficacy is limited. VA-ECMO is considered the first-line option, with a growing number of accepted and emerging indications. Randomized clinical trials are now needed to determine the place VA-ECMO in cardiogenic shock treatment strategies.

Acute myocardial infarction (AMI) caused by total occlusion of the left main coronary artery (LMCA) is a catastrophic event. However, the clinical features and appropriate treatment of patients with this condition remain unclear. We report a man with total occlusion of the LMCA presenting with AMI combined with cardiogenic shock. He was successfully treated with angioplasty and drug-eluting stent implantation assisted by an intra-aortic balloon pump (IABP). This case suggests that percutaneous coronary intervention may be an optional therapeutic strategy in these patients, and that IABP implantation could improve clinical outcomes. A dominant right coronary artery and enhanced collateral circulation were considered to be key features related to the patient’s survival.

Background Long-term survival benefits of full arterial revascularization with radial artery (RA) used in addition to bilateral internal mammary arteries (BIMA) compared with saphenous vein (SV) used in addition to BIMA has not been clearly defined. Methods We retrospectively analyzed 660 3-vessel coronary artery disease subjects who received BIMA in addition to either RA (n = 206) or SV (n = 454) grafting in a period between June 1999 and November 2017. After propensity score matching, we obtained 190 matched pairs for analysis. Results In the matched population, in-hospital mortality occurred in 4 patients (1%), with 2 deaths (1.1%) in the BIMA + RA group and 2 deaths (1.1%) in BIMA + SV group (P > .99). The median follow-up time was 9.2 years (interquartile range, 5.6-13 years) with a maximum follow-up time of 18.5 years. There was not a significant difference in long-term survival between the 2 groups over the follow-up period. Survival at 5, 10, and 15 years were 94.8 ± 1.7%, 83.7 ± 3.1%, and 78.6 ± 3.9% in the BIMA + RA group and 96.2 ± 1.4%, 85.1 ± 2.9%, and 80.4 ± 3.6% in the BIMA + SV group (stratified log-rank P = .78). Cox proportional hazard regression model was used to estimate that the use of RA in addition to BIMA did not affect the late mortality (propensity score adjusted hazard ratio, 1.05; 95% confidence interval, 0.62-1.79; P = .83). Conclusions In a relatively small population of triple-vessel coronary artery disease, the use of RA as a third arterial conduit with BIMA did not confer a long-term survival benefit.

Stress (Takotsubo) cardiomyopathy (CM) is defined as a transient regional systolic dysfunction of the left ventricle that mimics acute coronary syndrome (ACS) in the absence of significant coronary artery disease or plaque rupture. This phenomenon commonly occurs in postmenopausal females in the presence of emotional, physical and psychological stressors with excess catecholamine stimulation, resulting in diffuse microvascular spasm and subsequently myocardial stunning. Here we report a 58-year-old postmenopausal female patient with end stage renal disease (ESRD) who was presented to our hospital with a clinical picture suggesting ACS. Shortly after admission she progressed to cardiogenic shock and pulseless electrical activity (PEA) and was diagnosed retrospectively with Takotsubo cardiomyopathy. She was successfully treated with beta-blockers, IV fluids and inotropic agents. Intra-aortic balloon pump (IABP) was considered, however, the patient gradually improved to full recovery with resolution of left ventricular function back to normal.

The mortality rate from aluminum phosphide (AlP) poisoning is as high as 70–100%, with refractory hypotension and severe metabolic acidosis being the two most common presentations in this poisoning. As this poisoning has no specific antidote, treatments revolve around supportive care. Cardiogenic shock created by toxic myocarditis is considered the main cause of mortality in these patients. Meanwhile, the intra-aortic balloon pump (IABP) has been suggested for the treatment of cardiogenic shock. This article reports the successful treatment of cardiogenic shock caused by AlP poisoning in a 17-year-old man and a 21-year-old woman using the IABP procedure.

Objective Cardiac paragangliomas are rare neuroendocrine tumors. Early surgical treatment improves clinical symptoms and prolongs survival. We review our experience in 17 patients who underwent surgical resection for functional cardiac paraganglioma. Methods Seventeen patients underwent surgery for functional cardiac paraganglioma from 2004 to 2017 were identified. Clinical data and long-term outcomes were extracted and analyzed. Results All 17 patients with cardiac paraganglioma (11 males) with a median age of 35 years (range, 11 to 51 years) were hormonally functional and underwent operations. A 24-hour urine catecholamine assay documented elevation of norepinephrine, epinephrine, and dopamine. Tumors were determined with octreotide scintiscan in all 17 patients and metaiodoben-zylguanidine scintigraphy in 10 of 15 patients. Tumor sites were right atrioventricular groove in 4 patients, between the main arteries in 10 patients, and interatrial groove in 4 patients. All patients underwent complete resection. Concomitant surgeries were: structural reconstruction in 16 patients (94%) and coronary artery bypass graft in 8 patients (47%). One patient had a history of incomplete resection of an intra-atrial tumor. One patient died postoperatively. Operative mortality is 5.8%. During follow-up (mean, 6.5 years; range, 1.5 to 14.2 years), 16 patients are alive in functional class I or II. Two patients developed tumor recurrence and 14 remained symptom-free with normal urinary catecholamines. Conclusions With a multidisciplinary treatment, early diagnosis, complete resection for the tumor along with complex reconstruction is achievable for most patients, and it offers promising long-term survival.

To assess the influence of primary arterial access in patients receiving peripheral postcardiotomy extracorporeal life support on associated complications and outcome.Of 573 consecutive patients requiring PC-ECLS between 2000 and 2019 at a single center, 436 were included in a retrospective analysis and grouped according to primary arterial extracorporeal life support access site. Survival and rate of access-site-related complications with special emphasis on fatal/disabling stroke were compared.The axillary artery was cannulated in 250 patients (57.3%), whereas the femoral artery was used as primary arterial access in 186 patients (42.6%). There was no significant difference in 30-day (axillary: 62%; femoral: 64.7%; P = .561) and 1-year survival (axillary: 42.5%; femoral: 44.8%; P = .657). Cerebral computed tomography-confirmed stroke with a modified ranking scale ≥4 was significantly more frequent in the axillary group (axillary: n = 28, 11.2%; femoral: n = 4, 2.2%; P = .0003). Stroke localization was right hemispheric (n = 20; 62.5%); left hemispheric (n = 5; 15.6%), bilateral (n = 5; 15.6%), or infratentorial (n = 2; 6.25%). Although no difference in major cannulation site bleeding was observed, cannulation site change for bleeding was more frequent in the axillary group (axillary: n = 13; 5.2%; femoral: n = 2; 1.1%; P = .03). Clinically apparent limb ischemia was significantly more frequent in the femoral group (axillary: n = 12, 4.8%; femoral: n = 31, 16.7%; P .0001).Although survival did not differ, surgeons should be aware of access-site-specific complications when choosing peripheral PC-ECLS access. Although lower rates of limb ischemia and the advantage of antegrade flow seem beneficial for axillary cannulation, the high incidence of right hemispheric strokes in axillary artery cannulation should be considered.