Gordan Samoukovic

The Impella® LP 5.0 as a bridge to long-term circulatory support

Multi-organ failure (MOF) secondary to bi-ventricular cardiac dysfunction is a major therapeutic challenge. In addition to aggressive medical therapy, it frequently requires circulatory support with uni- or bi-ventricular assist devices. The Impella LP 5.0 is a new microaxial left ventricular assist device (LVAD). Microaxial LVADs have been used for short-term circulatory support in patients with cardiogenic shock due to myocarditis, post coronary artery bypass grafting (CABG), or during high-risk percutaneous coronary interventions (PCI). We present a case of a patient in bi-ventricular failure successfully bridged to permanent circulatory support. Relative merits of this therapeutic approach are outlined and discussed.

Successful treatment of heart failure due to acute transplant rejection with the Impella LP 5.0.

Cardiogenic shock resulting from transplant rejection is a serious complication with high mortality and morbidity. Often resistant to maximal medical therapy, this condition frequently requires mechanical circulatory support until recovery or retransplantation. We present a 52-year-old patient with multiorgan failure secondary to acute graft rejection after orthotopic heart transplantation. Maximal medical therapy was not successful, and the patient was bridged to recovery with an Impella LP 5.0 (Abiomed Inc, Danvers, MA) left ventricular assist device (LVAD). The relative merits of this therapeutic approach are outlined and discussed. The patient was discharged 3 weeks after LVAD removal and remains clinically stable.

Preoperative hospital length of stay as a modifiable risk factor for mediastinitis after cardiac surgery

BackgroundAs high-risk cardiac patients frequently remain within hospital while waiting for surgery, the aim of the present study was to determine the role of preoperative length of hospital stay on mediastinitis, and also, to assess contemporary risk factors for this complication.MethodsThe source population consisted of 6653 consecutive patients undergoing coronary bypass surgery, valve surgery, or both between September 2000 and September 2009 at a single tertiary care hospital. A retrospective cohort analysis was used to assess the effect of 18 preoperative variables, including length of stay, on mediastinitis.ResultsMediastinitis developed in 108 patients (1.6%) resulting in an in-hospital mortality rate of 13.9%. Independent predictors of mediastinitis included obesity (2.59, CI 1.58-4.23), COPD (2.44, CI 1.55-3.84), diabetes (2.16, CI 1.44-3.24), and impaired estimated glomerular filtration rate. Preoperative hospital stay was also found to be an independent risk factor leading to a 15% increased risk of mediastinitis per week of stay. The primary wound pathogen was coagulase negative staphylococcus (82%) followed by multi-flora isolates (49%), but was unrelated to hospital stay.ConclusionsIn addition to the traditional risk factors, prolonged preoperative hospital stay is also a significant and potentially modifiable predictor for the development of mediastinitis following cardiac surgery. All efforts should be made to minimize the delay in operating on hospitalized patients awaiting heart surgery.

Laparoscopic Splenectomy in a Patient with a Heartmate® II Left Ventricular Assist Device

INTRODUCTION Since the publication of the REMATCH trial results, it is estimated that almost 5 million Americans have been found to have heart failure. Limited availability of organs for transplantation, coupled with wider selection criteria for destination therapy, has resulted in a substantial increase in the number of patients with permanently assisted circulation. Given the high rate of complications related to circulatory assist devices, it is expected that these patients will be undergoing noncardiac surgical procedures more commonly. MATERIALS AND METHODS We describe a laparoscopic splenectomy in a patient supported with a Heartmate II left ventricular assist device. Using this case as a model, we discuss hemodynamic changes associated with pneumoperitoneum and anesthesia induction. Additionally, an extensive literature search was performed to asses the frequency of laparoscopic procedures performed on patients with circulatory support. RESULTS Laparoscopic splenectomy was performed without significant hemodynamic changes. To our knowledge, this is the first laparoscopic splenectomy performed in a patient with this mode of circulatory support. CONCLUSION Laparoscopic procedures can safely be performed in patients with compensated heart failure, who are supported with ventricular assist devices.

Floating thrombus in the aortic arch with systemic arterial embolization.

A 48-year-old male underwent emergent bilateral aorto-iliac embolectomy for acute leg pain and was found on chest computed tomography (CT) to have a 4.5-cm mass in the proximal ascending aorta (Fig. 1). The patient was taken to the operating room and placed on cardiopulmonary bypass through the femoral artery and right atrium. During a brief period of hypothermic circulatory arrest, the mass was noted to be attached to the posterior aspect of the aorta just above the sinotubular junction and extended to the proximal aortic arch (Fig. 2). This area was resected and continuity was restored with a 24-mm Gelweave interpostion graft (Vascutek-Terumo, Ann Arbor, MI, USA). The patient had an uncomplicated postoperative course and remains symptom free on aspirin and coumadin. The histology showed an organized thrombus without any pathological changes in the aortic wall.

Mediastinitis Post Cardiac Surgery and the Role of the Internal Mammary Artery: An Updated Risk Factors Analysis

84 CONCLUSION: Osmotic expander is a reliable tool for tissue expansion. The main advantages of this device make it especially suitable for children: Its initial small size allows for insertion through a small surgical incision. There is no need for a drain, and overall operating time is much shorter. The expansion period is more convenient for the patient. The need for external filling injections is eliminated and the risk of infections is lower. Its main disadvantages include the inability to control the filling rate and the necessity to remove it in case of damage to the surrounding tissue.