Aitor Uribarri

First series of mechanical circulatory support in non-compaction cardiomyopathy: Is LVAD implantation a safe alternative?

BACKGROUND Left ventricular non-compaction (LVNC) is a rare cardiac disorder characterized by prominent trabeculae and deep recesses of the ventricular myocardium. Patients with LVNC may develop severe congestive heart failure refractory to medical therapy. However, heart transplantation is strongly limited due to donor organ shortage. Thus mechanical circulatory support by left ventricular assist devices (LVADs) is a promising alternative. Nevertheless, hypertrabeculation and proarrhythmogenic potential in LVNC might represent important hurdles for success of LVAD therapy in these patients. METHODS AND RESULTS We retrospectively analyzed the data of a total of 5 patients (3 HVAD, Heartware®; 2 HeartMate II, Thoratec®) with LVNC who underwent LVAD implantation in our institution between 2010 and 2014. Mean follow-up time was 86.5weeks. 30-day survival was 100% without major intrahospital complications. During follow-up, 3 patients developed pump thrombosis requiring pump replacement. Arrhythmias were not detected during follow-up as assessed by ICD interrogation. CONCLUSIONS LVAD implantation in LVNC can be performed with low intrahospital complication rates. However, we observed a high incidence of pump thrombosis during follow-up, possibly related to thromboembolic predisposition by the underlying LVNC. Therefore, careful management of anticoagulation appears to be critical in these patients.

Impact of time to cooling initiation and time to target temperature in patients treated with hypothermia after cardiac arrest

Purpose: Little is known about the role of time to initiation of therapeutic hypothermia and time to target temperature (TTT) in the prognosis of patients resuscitated from cardiac arrest. Methods: A retrospective analysis was performed in 145 survivors of cardiac arrest who underwent therapeutic hypothermia between January 2003 and January 2013. The objective was to identify predictors of survival free from significant neurological sequelae (Cerebral Performance Categories Scale (CPC): >2) six months after cardiac arrest. We evaluated the effect of faster and earlier cooling. Results: Overall survival at six months was 42.1% (61 patients); 59 of these were considered to have a good neurological status (CPC≤2), and in whom therapeutic hypothermia was initiated earlier (87±17 min vs. 111±14 min; p=0.042), and the target temperature was reached at an earlier time (TTT: 316 ± 30 min vs. 365 ± 27 min; p=0.017). Multivariate analysis selected longer duration of cardiac arrest (odds ratio (OR) =1.06 per min), a non-shockable initial rhythm (OR=13.8), severe acidosis (OR=0.009 per 0.01 unit), older age (OR=1.04 per year) and longer TTT (OR=1.005 per min) as associated with poor prognosis. Conclusion: The most important prognostic factors for death or lack of neurological recovery in patients with cardiac arrest treated with therapeutic hypothermia are initial-rhythm, time from cardiac arrest to return of spontaneous circulation and arterial-pH at admission. Although the speed of cooling initiation and the time to reach target temperature may play a role, its influence on prognosis seems to be less important.

Pathological insights of a woven coronary artery with optical coherence tomography

A 78-year-old male was admitted to our centre because of III/IV CCS stable angina despite optimal medical treatment. Stress-induced myocardial ischaemia was demonstrated by SPECT in the inferior wall ( Panel A ), and a coronary angiography was performed. Severe coronary stenosis was observed in the first diagonal and in the circumflex. The right coronary artery (RCA) …

Left Ventricular Assist Device Therapy for Destination Therapy: Is Less Invasive Surgery a Safe Alternative?

INTRODUCTION AND OBJECTIVES The number of older patients with congestive heart failure has dramatically increased. Because of stagnating cardiac transplantation, there is a need for an alternative therapy, which would solve the problem of insufficient donor organ supply. Left ventricular assist devices (LVADs) have recently become more commonly used as destination therapy (DT). Assuming that older patients show a higher risk-profile for LVAD surgery, it is expected that the increasing use of less invasive surgery (LIS) LVAD implantation will improve postoperative outcomes. Thus, this study aimed to assess the outcomes of LIS-LVAD implantation in DT patients. METHODS We performed a prospective analysis of 2-year outcomes in 46 consecutive end-stage heart failure patients older than 60 years, who underwent LVAD implantation (HVAD, HeartWare) for DT in our institution between 2011 and 2013. The patients were divided into 2 groups according to the surgical implantation technique: LIS (n = 20) vs conventional (n = 26). RESULTS There was no statistically significant difference in 2-year survival rates between the 2 groups, but the LIS group showed a tendency to improved patient outcome in 85.0% vs 69.2% (P = .302). Moreover, the incidence of postoperative bleeding was minor in LIS patients (0% in the LIS group vs 26.9% in the conventional surgery group, P < .05), who also showed lower rates of postoperative extended inotropic support (15.0% in the LIS group vs 46.2% in the conventional surgery group, P < .05). CONCLUSIONS Our data indicate that DT patients with LIS-LVAD implantation showed a lower incidence of postoperative bleeding, a reduced need for inotropic support, and a tendency to lower mortality compared with patients treated with the conventional surgical technique.

Infective endocarditis in adults with congenital heart disease remains a lethal disease

Objective Infective endocarditis (IE) is associated with significant morbidity and mortality. Patients with adult congenital heart disease (ACHD) have an increased risk of developing IE. The aim of this study is to describe the incidence, predictors of outcome and mortality associated with IE in ACHD in a contemporary cohort. Methods All episodes of IE in adults with congenital heart disease referred to our tertiary centre between 1999 and 2013 were included in the study. Patients were identified from the hospital database. The diagnosis of endocarditis was established according to the modified Duke criteria. The primary endpoint of the study was endocarditis-associated mortality. Results There were 164 episodes of IE in 144 patients (male 102, 70.8%). Mean age at presentation was 32.3±22.7 years. Out of these, 43% had a simple, 23% a moderate and 32% a complex lesion. It was at least the second bout of IE in 37 episodes (23%). A predisposing event could be identified in only 26.2% of episodes. Surgical intervention during the same admission was performed in 61 episodes (37.2%). During a median follow-up of 6.7 years (IQR 2.9–11.4), 28 (19.4%) patients died. Out of these, 10 deaths were related to IE (IE mortality 6.9%). On unvariate regression analysis, the development of an abscess (OR: 7.23; 95% CI 1.81 to 28.94, p<0.01) and age (OR: 1.05; 95% CI 1.01 to 1.10, p=0.03) were the only predictors of IE-associated mortality. There was no increase in IE cases at our centre during the period of the study. Conclusions IE-associated morbidity and mortality in a contemporary cohort of ACHD patients is still high in the current era.

Percutaneous extracorporeal membrane oxygenation in electrical storm: five case reports addressing efficacy, transferring allowance or radiofrequency ablation support:

Extracorporeal membrane oxygenation systems have undergone rapid technological improvements and are now feasible options for medium-term support of severe cardiac or pulmonary failure. We report five cases of electrical storm that was rescued by the insertion of peripheral veno-arterial extracorporeal membrane oxygenation systems. This device could help to restore systemic circulation as well as permitting organ perfusion in patients with cardiogenic shock in relation to electrical storm thus achieving greater electrical stability. Also, in some cases extracorporeal membrane oxygenation support could facilitate electrophysiology study.

Percutaneous Venous-pulmonary Artery Extracorporeal Membrane Oxygenation in Right Heart Failure

Mechanical circulatory support with a left ventricular assist device (LVAD) is an established treatment for patients with advanced heart failure. Nonetheless, it is not free from complications, with right ventricular failure (RVF) being one of the most dreaded postprocedure events. Despite adequate risk stratification and optimal periprocedure treatment, some patients experience RVF and require a second circulatory assist device. Several devices and implantation techniques have been used for this purpose. We present the case of a patient who was treated with LVAD implantation, developed RVF, and underwent placement of a device for percutaneous venous-topulmonary artery extracorporeal membrane oxygenation (ECMO) for percutaneous right ventricular support. A 64-year-old woman with a history of dilated ischemic cardiomyopathy had severely depressed left ventricular function. In 2002, she underwent coronary artery revascularization surgery for disease of the left anterior descending artery and first diagonal artery. A left mammary to left anterior descending artery bypass and a saphenous to diagonal artery bridge were performed. The patient did not continue follow-up after the procedure. In 2015, she was admitted for heart failure. During hospitalization she showed severe left ventricular dysfunction (left ventricular ejection fraction 21%, end-diastolic volume 87 mL/m, end-systolic volume, 37 mL/m), and magnetic resonance imaging confirmed an absence of viability in the territory of the left anterior descending artery (Figure 1A). Coronary angiography showed a complex fistula that connected the left mammary arteries and left subclavian artery with the left

Prognostic Value of the Nutritional Risk Index in Candidates for Continuous Flow Left Ventricular Assist Device Therapy

INTRODUCTION AND OBJECTIVES Malnutrition has been shown to affect clinical outcomes in patients with heart failure. The aim of this study was to analyze the impact of preoperative nutritional status assessed by the nutritional risk index (NRI) on the prognosis of patients with a continuous-flow left ventricular assist device (cf-LVAD). METHODS We performed a retrospective study of 279 patients who underwent cf-LVAD implantation between 2009 and 2015 in our center. Preoperative NRI was calculated and the patients were followed-up for 1 year. The association between preoperative NRI and postoperative clinical events was analyzed using multivariable logistic regression. RESULTS The prevalence of severe (NRI <83.5), moderate (83.5 ≤ NRI <97.5) and mild (97.5 ≤ NRI <100) nutritional risk was 5.4%, 21.5%, and 9.3%. Mortality rates 1 year after cf-LVAD implantation in these 3 categories were 53.3%, 31.7%, 23.1% vs 18.0% (P <.001) in patients with a normal IRN. A normal preoperative NRI value was an independent predictor of lower risk of death from any cause during follow-up (aHR per 1 unit, 0.961; 95%CI, 0.941-0.981; P <.001) was and a predictor for a lower risk of postoperative infections (aOR, 0.968; 95%CI, 0.946-0.991; P=.007), respiratory failure (aOR, 0,961; 95%CI, 0.936-0.987; P=.004), and right heart failure (aOR, 0.963; 95%CI, 0.934-0.992; P=.014). CONCLUSIONS Malnourished patients are at increased risk for postoperative complications and death after cf-LVAD implantation. Assessment of nutritional risk could improve patient selection and the early initiation of nutritional support.

Use of intravenous iron in cyanotic patients with congenital heart disease and/or pulmonary hypertension

BACKGROUND Secondary erythrocytosis is common in patients with cyanosis secondary to congenital heart disease (CHD) and/or pulmonary hypertension (PH). This compensatory mechanism aims at increasing oxygen delivery to the tissues, but it requires adequate iron stores. Optimal methods of iron supplementation in this setting remain controversial, with fears of excessive erythropoiesis and hyperviscosity symptoms. We describe our experience using intravenous ferrous carboxymaltose. METHODS AND RESULTS 142 consecutive cyanotic patients were treated over 5.7 years (201 administrations). Mean age was 51.3 ± 17.6 years and 55 (38.7%) were male. Eisenmenger syndrome (ES) was present in 41 (28.8%), other pulmonary arterial hypertension (PAH) related to CHD (PAH-CHD) in 27 (19.0%), cyanotic CHD without PAH in 16 (11.3%) and PH without CHD in 58(40.8%). Baseline haemoglobin (Hb) concentration was 14.6 ± 3.0 g/dL and haematocrit 0.45 ± 0.09. A 500 mg dose of intravenous (IV) iron carboxymaltose was given in 163 (81.1%) of administrations and a 1000 mg dose in 37 (18.4%). A significant improvement in average Hb, haematocrit, ferritin and transferrin saturation was observed after a median follow-up of 100.0 [70.0-161.0] days (p ≤ 0.0001 for all). There were no cases of excessive erythropoiesis resulting in new hyperviscosity symptoms and/or requiring venesection. A minor transient rash was observed in 2 patients and one patient experienced an air embolus causing a transient ischemic attack. CONCLUSIONS Intravenous ferrous carboxymaltose appears to be safe in iron deficient patients with cyanosis due to CHD and/or PH, as long as care is taken to avoid air emboli. Further randomised studies are needed to confirm the safety and efficacy of intravenous iron in this setting.

Implantation of Ventricular Assist Devices in Hypertrophic Cardiomyopathy. Is It a Safe Option

adrenaline and milrinone to reduce the probability of right heart failure, as the authors mention. However, in this case, by not performing a myectomy despite the dynamic left ventricular outflow gradient, they may have created the ideal environment for suction events. The vasoactive support could have increased the left ventricular outflow tract gradient and also created a high intraventricular gradient due to the increased midventricular inotropy facilitated by the adrenaline, together with the suction created by the LVAD. Considering these factors, despite the good outcome described, we believe that the performance of myectomy during implantation could help to improve the postoperative treatment of patients with obstructive left ventricular outflow tract gradients. We would like to add that long-term ventricular assistance in cardiomyopathies with restrictive physiology is a challenge. The most important determining factor when considering LVAD implantation in these patients is probably the dimensions of the cardiac chambers. Grupper et al. reported the largest published series of patients with cardiomyopathy, restrictive physiology, and LVADs, and observed that patients with smaller ventricles had a worse prognosis. In such patients, it is generally very difficult to achieve adequate ventricular assistance because they are very sensitive to volumetric changes and they are prone to suction events with postural changes. This often means that the revolutions of the device have to be reduced to avoid the cavity collapsing, and this, in turn, increases the risk of pump thrombosis and/or embolic events. Therefore, careful anticoagulant and antiplatelet therapy is required in these patients. Last, we would like to congratulate the authors once more on the good outcome they achieved, although in our opinion LVAD therapy in cardiomyopathy with restrictive physiology is not free from significant complications and should be reserved for centers with a high annual caseload.