Iosif Gulkarov

Pulmonary Embolectomy in the Treatment of Submassive and Massive Pulmonary Embolism

Objectives: Significant improvements in outcomes after pulmonary embolectomy have resulted in a broadening of indications. We reviewed our experience with pulmonary embolectomy over the past 12 years with an emphasis on preoperative comorbidities and postoperative morbidity and mortality. Methods: All patients undergoing pulmonary embolectomy over the past 12 years at our institution were analyzed via retrospective chart review. Data on preoperative characteristics, operative procedures and postoperative outcomes were collected. Results: Twenty patients underwent pulmonary embolectomy between 1999 and 2011. The average age was 56 years (range 24-81) and 10 patients (50%) were female. All patients demonstrated right ventricular dysfunction and 19 (95%) demonstrated contraindications to thrombolysis. Twelve patients (60%) demonstrated intermittent hypotension, 4 (20%) required intubation and 3 (15%) demonstrated preoperative or intraoperative cardiac arrest. Survival to discharge was 95%. Conclusions: Pulmonary embolectomy has been shown to be safe and effective in the treatment of massive pulmonary embolism (PE). We achieved a 95% survival rate in a cohort of patients with significant comorbid status. Pulmonary embolectomy should be considered early in the therapeutic algorithm for patients with submassive PE presenting with right ventricular dysfunction to prevent progression. It can also be performed with good outcomes in those already suffering hemodynamic compromise.

Heparin Induced Thrombocytopenia and Cardiac Surgery: A Comprehensive Review

Heparin induced thrombocytopenia presents as an underdiagnosed condition with life threatening thrombotic complications. The incidence in cardiac surgery patients is dependent on several factors and appeared to be greater in procedures that involve the use of intraaortic balloon pump. Clinical diagnosis is particularly challenging in cardiac surgery patients due to the natural occurrence of post-operative thrombocytopenia. High index of suspicion is key factor to establish adequate treatment and prevent the occurrence of thrombotic complications, such as saphenous vein graft occlusion, pulmonary embolism and myocardial infarction, which lead to substantially increased mortality rates. The 4T’s assessment point system was designed in order to evaluate the likelihood of occurrence of the condition based on clinical presentation; however, serotonin release assay represents the gold standard to reach diagnosis. Treatment of heparin induced thrombocytopenia involves cessation of unfractionated and fractionated heparin, and the instauration of therapy with direct thrombin inhibitors. Among all direct thrombin inhibitors agents, Bivaluridin is emerging as a potential first line of treatment based on its benefits of a short half-life and enzymatic elimination.

A Hybrid Approach in the Treatment of Post-Myocardial Infarction Ventricular Septal Defect

Development of ventricular septal defect (VSD) is a rare but serious complication of transmural myocardial infarction (MI). The incidence of post-MI VSDs is reduced significantly with thrombolytic therapy, yet mortality remains high. Surgical repair is difficult and can be complicated by a recurrent VSD in some cases. Percutaneous catheter-based closure techniques can be used to treat these patients. This case report demonstrates the successful application of a hybrid approach utilizing initial surgical and subsequent percutaneous techniques for the recurrence in the treatment of a post-MI VSD.

Factors Associated with Successful Thrombus Extraction with the AngioVac Device: An Institutional Experience

BACKGROUNDnThe AngioVac (AngioDynamics, Latham, NY) device utilizes a venovenous bypass circuit for percutaneous venous thrombectomy and has been applied in the setting of iliocaval thrombosis as well as right heart thrombus and pulmonary emboli. We describe our experience with the AngioVac device in 12 patients with a variety of indications with the goal of identifying factors correlating with successful thrombectomy.nnnMETHODSnFrom August 2013 to June 2015, 12 patients underwent AngioVac percutaneous thrombectomy at our institution. Preoperative, intraoperative, and postoperative data were retrospectively analyzed.nnnRESULTSnIndications for thrombectomy included iliocaval thrombosis in 33% (4), right heart thrombus in 42% (5), and pulmonary embolus in 25% (3). We experienced a 58% complete success rate. Partial success was achieved in 17%, and no thrombus was extracted in 25%. Iliocaval and right heart thrombi were the most amenable to AngioVac thrombectomy with 100% (4/4) and 60% (3/5) complete success rates, respectively. Pulmonary embolus was the least amenable to thrombectomy with a 33% partial success rate (1/3) and 67% failure rate (2/3).nnnCONCLUSIONnThe AngioVac devices allow for percutaneous thrombectomy in the setting of iliocaval and right heart thrombus in patients for whom medical therapy fails or for those in whom surgical intervention is considered high risk. Pulmonary emboli are less amenable, likely due to limited steeribility of the device. Larger studies are needed to make more definitive conclusions, and newer iterations of the device will likely allow for improved outcomes.

Transapical mitral valve-in-valve implantation for patients in cardiogenic shock.

Transcatheter aortic valve implantation has demonstrated excellent results in high risk and inoperable patients, and been extended to valve-in-valve implantation for those with prosthetic aortic and, more recently, mitral valve failure. Despite its use in high risk and inoperable patients, active cardiogenic shock has historically been considered a contraindication. We describe 2 patients in acute cardiogenic shock from prosthetic mitral valve failure treated with transcatheter mitral valve-in-valve implantation. Transcatheter mitral valve therapies should be considered in patients in cardiogenic shock from prosthetic mitral valve failure, although, larger studies are needed to make any strong recommendation.

Paradoxical embolus in transit.

Thrombus straddling a patent foramen ovale, namely, a paradoxical embolus in transit, is a rarely identified entity signifying impending arterial embolism. We report a series of 3 patients with preoperatively or intraoperatively identified paradoxical embolus in transit. All patients underwent surgical evacuation and had unremarkable postoperative courses with no episodes of arterial embolization. Surgical embolectomy should be considered early in the treatment of paradoxical embolus in transit.

TRANSCATHETER AORTIC VALVE IMPLANTATION IS SAFE IN PATIENTS WITH LEFT ATRIAL THROMBUS OR SPONTANEOUS ECHO CONTRAST

Background: Left atrial thrombus (LAT) and spontaneous echo contrast (SEC) are risk markers for cardioembolization. LAT was an exclusion criterion in the transcatheter aortic valve replacement (TAVR) trials although such patients undergo TAVR in the “real-world” setting. In this study we analyze

Cardiac Amyloidosis Presenting With Cardiogenic Shock.

Cardiac amyloidosis is an infiltrative disorder of the myocardium. It is the result of one of 4 types of amyloidosis: primary systemic (immunoglobulin light chain), secondary, familial (hereditary), or senile. Cardiac amyloidosis ultimately causes congestive heart failure due to irreversible restrictive cardiomyopathy. Because of the rapid progression of the disease, early recognition and determination of underlying etiology are important for tailored therapy. Current interventions range from conservative heart failure management to autologous stem cell and heart transplantation. We present a case of cardiac amyloidosis accompanying undiagnosed multiple myeloma to illustrate the rapid progression of the disease and the complexities of diagnosing and treating this disorder.

Ascending aortic aneurysm repair and surgical ablation for atrial fibrillation.

BackgroundAlthough surgical ablation of atrial fibrillation is commonly performed during concomitant coronary or valve surgery, it is still only performed in a fraction these cases when indicated, and less often in patients undergoing aneurysm surgery. We describe our experience in patients undergoing ascending aneurysm repair and concomitant atrial fibrillation ablation.MethodsFrom January 2004 until November 2011, 40 patients underwent ascending aneurysm repair and atrial fibrillation ablation at our institution and were retrospectively analyzed.ResultsAverage age was 67.6xa0years (43–85). Root replacement was performed in 23 (57.5xa0%) and arch replacement with circulatory arrest in 18 (45xa0%). At an average of 41.8xa0months, 81xa0% of patients were in sinus rhythm. Operative survival was 100xa0%, with 1 and 5 year survival of 97.5 and 93.1xa0%, respectively. Kaplan-Meier analysis revealed improved overall survival in patients with rhythm success (log-rank test pu2009=u20090.037).ConclusionsAortic aneurysm repair with concomitant atrial fibrillation ablation is safe and efficacious despite the requirement for an already extensive procedure with rhythm success rates similar to those quoted in the setting of other procedures. Successful restoration of sinus rhythm improves long term survival and should be considered in patients presenting with aortic aneurysm and atrial fibrillation.