George Batsides

The Impella Device for Acute Mechanical Circulatory Support in Patients in Cardiogenic Shock

BACKGROUND Acute cardiogenic shock is associated with high mortality rates. Mechanical circulatory devices have been increasingly used in this setting for hemodynamic support. The Impella device (Abiomed Inc, Danvers, MA) is a microaxial left ventricular assist device that can be inserted using a less invasive technique. This study was conducted to determine the outcome of patients who have undergone placement of the Impella device for acute cardiogenic shock in our institution. METHODS A retrospective record review of 47 patients who underwent placement of the Impella device was performed from January 1, 2006, to December 31, 2011. Records were evaluated for demographics, operative details, and postoperative outcomes. Operative mortality was defined as death within 30 days of the operation. RESULTS The patients (33 male) were an average age of 60.23 ± 13 years. The indication for placement of the Impella device included cardiogenic shock in 15 patients (32%) and postcardiotomy cardiogenic shock in 32 (68%). Of the 47 patients, 38 (80%) received the Impella 5.0 and the rest the 2.5 device. Ventricular function recovered in 34 of 47 patients (72%), and the device was removed, with 4 patients (8%) transitioned to long-term ventricular assist devices. The 30-day mortality was 25% (12 of 47 patients). Complications occurred in 14 patients (30%), consisting of device malfunction, high purge pressures, tube fracture, and groin hematoma. CONCLUSIONS This is one of the largest series of patients undergoing placement of the Impella device for acute cardiogenic shock. Our outcomes showed improved results compared with historical data. Myocardial recovery was accomplished in most patients. Finally, the 30-day mortality and complication rate was acceptable in these critical patients. These benefits were all achieved with the Impella device in a less invasive method.

Acute Biventricular Mechanical Circulatory Support for Cardiogenic Shock

Background Biventricular failure is associated with high in‐hospital mortality. Limited data regarding the efficacy of biventricular Impella axial flow catheters (BiPella) support for biventricular failure exist. The aim of this study was to explore the clinical utility of percutaneously delivered BiPella as a novel acute mechanical support strategy for patients with cardiogenic shock complicated by biventricular failure. Methods and Results We retrospectively analyzed data from 20 patients receiving BiPella for biventricular failure from 5 tertiary‐care hospitals in the United States. Left ventricular support was achieved with an Impella 5.0 (n=8), Impella CP (n=11), or Impella 2.5 (n=1). All patients received the Impella RP for right ventricular (RV) support. BiPella use was recorded in the setting of acute myocardial infarction (n=11), advanced heart failure (n=7), and myocarditis (n=2). Mean flows achieved were 3.4±1.2 and 3.5±0.5 for left ventricular and RV devices, respectively. Total in‐hospital mortality was 50%. No intraprocedural mortality was observed. Major complications included limb ischemia (n=1), hemolysis (n=6), and Thrombolysis in Myocardial Infarction major bleeding (n=7). Compared with nonsurvivors, survivors were younger, had a lower number of inotropes or vasopressors used before BiPella, and were more likely to have both devices implanted simultaneously during the same procedure. Compared with nonsurvivors, survivors had lower pulmonary artery pressures and RV stroke work index before BiPella. Indices of RV afterload were quantified for 14 subjects. Among these patients, nonsurvivors had higher pulmonary vascular resistance (6.8; 95% confidence interval [95% CI], 5.5–8.1 versus 1.9; 95% CI, 0.8–3.0; P<0.01), effective pulmonary artery elastance (1129; 95% CI, 876–1383 versus 458; 95% CI, 263–653; P<0.01), and lower pulmonary artery compliance (1.5; 95% CI, 0.9–2.1 versus 2.7; 95% CI, 1.8–3.6; P<0.05). Conclusions This is the largest, retrospective analysis of BiPella for cardiogenic shock. BiPella is feasible, reduces cardiac filling pressures and improves cardiac output across a range of causes for cardiogenic shock. Simultaneous left ventricular and RV device implantation and lower RV afterload may be associated with better outcomes with BiPella. Future prospective studies of BiPella for cardiogenic shock are required.

MINIMALLY INVASIVE MITRAL VALVE SURGERY: THE NEW GOLD STANDARD?

Full sternotomy was the traditional approach to mitral valve surgery, but minimally invasive techniques, like right anterior mini-thoracotomy, have the proposed benefits of shorter length of stay (LOS) and fewer complications. Opponents of mini-thoracotomy, however, describe poor exposure and longer

Pericardial Angiosarcoma: An Elusive Diagnosis

The diagnosis of pericardial angiosarcoma is rare. We present a 33 year-old man with recurrent hemorrhagic pericardial effusions ultimately diagnosed with pericardial angiosarcoma by surgical biopsy. This case report highlights the challenges in diagnosing primary pericardial malignancy.

The Impella Device as a Temporary Bridge for Acute Mechanical CirculatorySupport

The mortality rate from cardiogenic shock after acute myocardialinfarction (MI) is high without reperfusion (70%-80%) [1]. Early revascularization is the basis of treatment of acute MI complicated by cardiogenic shock. Mechanical circulatory devices provide additional support for patients with refractory cardiogenic shock after revascularization alone has failed. These devices have been shown in the literature to improve outcomes in contrast to pharmacologic agents and/or intra-aortic balloon pump (IABP) demonstrated in the literature [2]. Short-term ventricular assists devices (VADs) can be initiated quickly and do not necessarily require a sternotomy. The Impella devices are minimally invasively placed, catheter mounted microaxial flow pumps. They are designed to directly unload the left ventricle, reduce myocardial workload and oxygen consumption while increasing cardiac output, coronary and end-organ perfusion. The purpose of our study is to review a patient who presented with acute cardiogenic shock and was treated with an Impella 5.0 device for temporarymechanical support.

Refractory Hypertension Leads to both Type A and B Aortic Dissections in a Single Patient

more prevalent in the population of patients with Type B dissections at 76.7% vs. those with Type A dissections at 69.3% there was no significant difference between the high proportion in these two groups (p=0.08) [8]. This contribution to aortic dissection is also remarkable in that the most affected demographic for either aortic dissection type is typically male (65.3%) and Caucasian (82.8%) with a mean age of 63.1 ± 14 years, with the rest of the patient population comprised of only1.7% African American and 13.5% Asian patients [8]. In each circumstance, the most common presenting symptom was found to be abrupt onset of sharp pain of the utmost severity either in the anterior chest in Type A dissections (p<0.001) or back in Type B dissections (p<0.001), which this patient also experienced. Patients were also found to present with systolic hypertension on physical exam most commonly (49%) with significantly more during a Type B vs [8]. Type A aortic dissection (70.1% vs. 35.7% respectively, p<0.001), with Type A dissections presenting significantly more with new-onset murmur of aortic insufficiency (44%, p<0.001), pulse deficit (18.7%, p=0.006), and congestive heart failure (8.8%, p=0.02) [8]. The most common imaging modality used to detect aortic dissection was computed tomography (61.1%) [8], which was used in the diagnosis of this patient (Figure 1). Only 3.9% of patients with a Type A aortic dissection had experienced a previous unspecified type dissection versus 10.6% of patients with a Type B aortic dissection (p<0.005), making this

The Impact of Gastrointestinal Complications on Patients who Undergo Coronary Artery Bypass Grafting

Objective: The incidence of gastrointestinal (GI) complications in patients undergoing coronary artery bypass grafting (CABG) is increasing as the population ages. The reported incidence ranges from 0.3% to 3.7%. Coronary Artery Bypass Grafting (CABG) is one of the most common operations performed. The outcome of patients who undergo abdominal operations for GI complications after CABG is not known. The purpose of the study is to determine the impact of abdominal surgery on patients who undergo CABG. Methods: A retrospective review of nationwide data of all patients undergoing CABG from 2006 to 2010. A total of 160,513 patients who underwent CABG were reviewed. Results: A total of 236 patients out of the 160,513 patients who underwent CABG developed GI complications that required abdominal surgery. The abdominal procedures included small and large bowel resections as well as colostomy formation. The indications for abdominal surgery varied and included ischemic bowel, and bowel obstruction. The patients who underwent concomitant abdominal surgery were more likely to develop renal Confidence Interval (CI) (8.5 to 14.2) (P<0.0001), respiratory CI (8.5 to 14.8) (P<0.0001), and infectious CI (16.3 to 28.6) (P<0.0001) complications. They were also more likely to have higher mortality CI (16.2 to 29.0), (P<0.0001). Patients who underwent abdominal operations had longer length of stay (LOS) 37.23 ± 32.8 days versus 8.2 ± 6.1 days (P<0.0001) and higher hospital charges,

Outcome of the impella device for acute mechanical circulatory support.

389,586 ± 2 60,546 compared to

Outcomes of Impella 5.0 in Cardiogenic Shock: A Systematic Review and Meta-analysis

111,290 ± 82,462.2 (P<0.0001). Conclusion: Although rare, the impact of abdominal surgery resulting from GI complications is significant. The patients who had abdominal surgery and underwent CABG were more likely to develop multiple complications. As a result, these patients had a higher rate of mortality, longer LOS, and higher hospital costs. Taken together, these results indicate that patients with GI complications should be identified promptly and aggressively treating these patients is of paramount importance.