Ed Peng

Durable Ventricular Assist Device Support for Failing Systemic Morphologic Right Ventricle: Early Results

BACKGROUNDnThe systemic morphologic right ventricle (RV) in congenitally corrected transposition of the great arteries or after atrial switch for transposition of the greatxa0arteries is associated with late ventricular failure. Although the role of the left ventricular assist device (LVAD) in supporting the failing LV is established, the indications and outcomes of using LVAD in a systemic RV remain unclear. We assessed the role of a third-generation LVAD for systemic RV support.nnnMETHODSnSeven patients (mean age, 36 years) received the HeartWare (HeartWare International Inc, Framingham, MA) VAD for systemic RV failure (congenitally corrected transposition of the great arteries in 1 and after atrial switch in 6). Four patients (57%) had severe subpulmonic LV failure, and aggressive perioperative diuresis with or without hemofiltration was used to offload the subpulmonic LV. The indications of VAD were (1) bridge to transplant in 3 and (2) bridge to decision for a high transpulmonary gradient in 4. Transplantation outcome was compared with systemic RV failure without VAD bridge in 19 patients (years 1989 to 2013).nnnRESULTSnSystemic RV support alone was achieved in all patients, with no early deaths (≤30 days). Overall, 6xa0(86%) returned home, 3 (44%) received a transplant, 2xa0(28%) died of noncardiac causes, and 2 (28%) continue on VAD support (median support, 232 days). Repeat catheterization (nxa0= 4) showed an improved median transpulmonary gradient in 3 patients (median 18.5 mm Hg pre-VAD vs 8.0 mm Hg post-VAD). Two bridge-to-decision patients received transplants at 640 and 685 days. The stroke rate on VAD support was 43% (2 thromboembolic and 1 hemorrhagic; 3 with satisfactory recovery). De novo aortic regurgitation was 29% (nxa0= 2; 1 valve replacement). All patients (nxa0= 3) survived transplantation (vs 10.5% early mortality without VAD bridge; pxa0= 1.00) and were well at follow-up (range, 53 to 700 days).nnnCONCLUSIONSnThe third-generation VAD provides durable support for systemic RV failure as a bridge to transplant and as a strategy to reduce pulmonary vascular resistance. Although concomitant subpulmonic LV failure is common, systemic RV support alone was achieved in all patients.

An Extended Role of Continuous Flow Device in Pediatric Mechanical Circulatory Support

BACKGROUNDnMechanical circulatory support in the pediatric population is currently limited to pulsatile ventricular assist devices (VAD). In recent years, the use of durable, newer generation, continuous flow devices have increased substantially among adults with end-stage heart failure. We examined the extended role of this device in the pediatric population (aged less than 18xa0years).nnnMETHODSnBetween 2010 and 2015, 12 patients (median age 7.1 years; range, 3.7 to 17.0; one third of patients were aged 5 years or less) received a HeartWare ventricular assist device (HVAD; HeartWare, Framingham, MA), 11 for cardiomyopathy and 1 for posttransplant rejection. Right VAD support (nxa0= 5; 42%) was provided by a short-term device (Levitronix, Zurich, Switzerland).nnnRESULTSnOverall, 1 patient died (day 638), 8 patients (67%) underwent transplantation, 1 patient (8.3%) recovered, and 2 patients (17%) remain on HVAD. The mean length of support was 150 days (range, 16 to 638). Four patients (33.3%) were discharged home (all left VAD). In the left VAD group (nxa0= 7), 3 patients subsequently received transplants (days 185, 201, and 234, respectively), 1 recovered (day 149), 1 died (day 638), 1 remained on HVAD (day 198), and 1 needed conversion to biventricular assist device (BIVAD [day 73]). In the BIVAD group (nxa0= 5), right VAD was weaned in 3 (60%), all subsequently received transplants, and 2 remained on BIVAD support until transplant (days 16 and 17, respectively). One BIVAD patient required conversion to central cannulation for longer-term support. Four BIVAD patients (80%) were in Interagency Registry for Mechanically Assisted Circulatory Support level 1 before VAD compared with 2 (29%) in the left VAD group (pxa0=xa0not significant). The actuarial survival rate was 100% at 1 year with no neurologic events.nnnCONCLUSIONSnThe third-generation, continuous flow device can provide durable support in the pediatric population. The selection strategy for patients who benefit most from the device continues to evolve. It is anticipated that a smaller design in the future will benefit an even wider pediatric population with heart failure.

Successful HeartWare Bridge to Recovery in a 3-Year Old: A Game Changer?

We report a 3-year-old boy weighing 13.5 kg who presented with intractable cardiac failure resulting from myocarditis and was treated by implantation of a HeartWare (HVAD) device. He was discharged home with the device. His cardiac function subsequently recovered, and the device was decommissioned. We believe this to be the youngest HVAD recipient and the only child to have recovered and had the device decommissioned.

Training the novice to become cardiac surgeon: does the "early learning curve" training compromise surgical outcomes?

ObjectiveIt is unclear whether novice trainees can be taught safely to perform adult cardiac surgery without any impact on early or late outcomes.MethodsAll patients (nxa0=xa01305) data were obtained from an externally validated, mandatory institutional database (2003–2010). ‘Novice’ is defined as a trainee who required substantial assistance or supervision to perform part or whole of the specified procedure (Intercollegiate Surgical Curriculum Programme UK, Competency Level ≤2). Outcome measures were in-hospital mortality, composite score of in-hospital mortality-morbidities, mid-term survival and revascularisation rate after CABG. Follow-up up to 7 years (median 3.2xa0years) was determined.ResultsSome 39xa0% (nxa0=xa0510) of the cases involved novice (28xa0%-part, 11xa0%-whole procedure), 12xa0% (nxa0=xa0157) competent trainees and 49xa0% (nxa0=xa0638) consultant. Median EuroSCORE was higher in consultant group (pxa0<xa00.001). Without risk adjustment, composite outcome score and mid-term mortality were higher in consultant group (pxa0=xa00.03). With adjustment using EuroSCORE and propensity scores, EuroSCORE was significantly predictive of in-hospital mortality [odd ratio (OR) 1.38, 95xa0%CI 1.20–1.57, pxa0<xa00.001], composite outcome (OR 1.26, 95xa0%CI 1.15–1.37, pxa0<xa00.001) and mid-term mortality (HR 1.24, 95xa0%CI 1.18–1.31, pxa0<xa00.001) but not the operator categories. Further analysis of subcohort undergoing first-time, isolated CABG (nxa0=xa01070) showed that EuroSCORE remained predictive of adjusted in-hospital mortality (OR 1.39, 95xa0%CI 1.13–1.71, pxa0=xa00.002), composite outcome (OR 1.33, 95xa0%CI 1.19–1.49, pxa0<xa00.001) and mid-term mortality (HR 1.22, 95xa0%CI 1.10–1.35, pxa0<xa00.001). The operator categories were not associated with adjusted outcome measures including revascularisation rate after CABG.ConclusionSupervised training in adult cardiac surgery can be achieved safely at the early learning curve phase without compromising both early and mid-term clinical outcomes.

Restrictive Cardiomyopathy or Constrictive Pericarditis: An Unresolved Conundrum

Cardiomyopathy may have a variety of causes and may lead to significant morbidity. Often, there is no “perfect” treatment. New investigative techniques may add insight but retain the possibility of uncertainty. The distinction between restrictive cardiomyopathy and pericardial constriction may be challenging, particularly when considering the incidence of these entities. This distinction may significantly impact patient management and this is becoming increasingly important in the context of donor organ austerity. We present a case of a 17-year-old male to illustrate the overlap highlighting this debate and our subsequent management.

Surgical Approach for Hypoplastic Mirror Circumflex Aortic Arch

Surgical approach for the mirror-form of circumflex aortic arch with a long-segment hypoplasia is described. Instead of uncrossing the arch, posterior aortic translocation of the aorta is required for the mirror-form. These surgical strategies addressed all the associated patho-mechanisms: (1) relief of vascular ring, (2) removal of posterior arch compression on the trachea, and (3) correction of any arch obstruction. Posterior tracheobronchopexy was further required to address severe underlying tracheobronchomalacia.

Epicardial implantation of a transvenous implantable cardioverter-defibrillator system in Ebstein's malformation with tricuspid valve repair

In this case report, we describe the implant of a transvenous implantable cardioverter-defibrillator lead on the left ventricular epicardial surface of a young patient with Ebsteins anomaly, facilitating effective defibrillation and anti-tachycardia pacing. The difficulties of conventional placement in Ebsteins malformation as well as the technique and outcome of epicardial lead implantation of a transvenous defibrillator-pacer system are discussed. <Learning objective: This case report highlights the possible placement of a conventional transvenous defibrillator lead on alternative site such as epicardial surface as a solution in patients with Ebsteins anomaly undergoing open heart surgery. This case report also discusses technical challenges, which precluded the transvenous implantation route in a post-operative patient with Ebsteins anomaly. The advantages of epicardial versus subcutaneous system are also discussed.>.

Surgical embolectomy is underused

Pulmonary embolism remains a major healthcare burden and some patients still die from this preventable disease, perhaps because of limited knowledge about available treatments for massive pulmonary embolism.1nnSystemic thrombolysis has been the mainstay for massive pulmonary embolism. Other options include transcatheter clot removal and locally directed thrombolysis, but their application is …