John R. Doty

End-of-life decision making and implementation in recipients of a destination left ventricular assist device

BACKGROUND The use of left ventricular assist devices (LVADs) as destination therapy (DT) is increasing and has proven beneficial in prolonging survival and improving quality of life in select patients with end-stage heart failure. Nonetheless, end-of-life (EOL) issues are inevitable and how to approach them underreported. METHODS Our DT data registry was queried for eligible patients, defined as those individuals who actively participated in EOL decision making. The process from early EOL discussion to palliation and death was reviewed. We recorded the causes leading to EOL discussion, time from EOL decision to withdrawal and from withdrawal to death, and location. Primary caregivers were surveyed to qualify their experience and identify themes relevant to this process. RESULTS Between 1999 and 2009, 92 DT LVADs were implanted in 69 patients. Twenty patients qualified for inclusion (mean length of support: 833 days). A decrease in quality of life from new/worsening comorbidities usually prompted EOL discussion. Eleven patients died at home, 8 in the hospital and 1 in a nursing home. Time from EOL decision to LVAD withdrawal ranged from <1 day to 2 weeks and from withdrawal until death was <20 minutes in all cases. Palliative care was provided to all patients. Ongoing assistance from the healthcare team facilitated closure and ensured comfort at EOL. CONCLUSIONS With expanding indications and improved technology, more DT LVADs will be implanted and for longer durations, and more patients will face EOL issues. A multidisciplinary team approach with protocols involving DT patients and their families in EOL decision making allows for continuity of care and ensures dignity and comfort at EOL.

Performance of the CryoValve* SG human decellularized pulmonary valve in 342 patients relative to the conventional CryoValve at a mean follow-up of four years

OBJECTIVE This study compared clinical outcomes of patients receiving CryoValve SG decellularized pulmonary valves with those of patients receiving conventionally processed CryoValve pulmonary valves. METHODS All consecutive patients undergoing Ross procedures and right ventricular outflow tract reconstructions with SG valves at 7 institutions (February 2000-November 2005) were assessed retrospectively (193 Ross procedures, 149 right ventricular outflow tract reconstructions). Patient, procedural, and outcome data were compared with those from 1246 conventional implants (665 Ross procedures, 581 right ventricular outflow tract reconstructions). Hemodynamic function was assessed at latest follow-up. RESULTS Follow-up was complete for 99% in SG group and 94% in conventional group, with mean follow-ups of 4.0 years (range, 0-6.7 years) for SG and 3.7 years (range, 0-6.7 years) for conventional. Five-year cumulative survivals and freedoms from adverse events were comparable between SG and conventional valves. Among patients undergoing Ross procedures, peak gradient at last follow-up was lower with SG valves (P < .01); no difference was observed in the right ventricular outflow tract reconstruction population. Pulmonary insufficiency was significantly reduced with SG valves in patients undergoing both Ross procedures (P < .01) and right ventricular outflow tract reconstructions (P < .01). Valve type was not a significant predictor of valve-related failure in propensity-adjusted analysis of either procedure. CONCLUSIONS CryoValve SG decellularized pulmonary valves have acceptable clinical outcomes and favorably compare with conventionally processed valves. Improved hemodynamic function observed with SG valves could signify improved long-term outcomes and may be due to the decreased antigenicity of these valves.

Differential impact on post‐transplant outcomes between pulsatile‐ and continuous‐flow left ventricular assist devices

Ventura PA, Alharethi R, Budge D, Reid BB, Horne BD, Mason NO, Stoker S, Caine WT, Rasmusson B, Doty J, Clayson SE, Kfoury AG. Differential impact on post‐transplant outcomes between pulsatile‐ and continuous‐flow left ventricular assist devices.
Clin Transplant 2011: 25: E390–E395.

Cardiac magnetic resonance imaging for perioperative evaluation of sternal eversion for pectus excavatum

OBJECTIVES Pectus excavatum is associated with varying degrees of exercise intolerance and symptomatology. Various forms of evaluation have been inconsistent in identifying objective data for correlation with symptoms. Cardiac magnetic resonance (CMR) imaging provides a promising method for delineating the anatomical and physiological components of pectus excavatum as well as measuring the results of surgical repair. METHODS Six patients with symptomatic pectus excavatum underwent preoperative evaluation with CMR. All patients had successful, uncomplicated repair of pectus excavatum using the sternal eversion technique. At the first postoperative visit, all patients underwent postoperative evaluation with CMR. Pre- and postoperative CMR measurements were compared for each patient. RESULTS Preoperative CMR demonstrated evidence of anatomical and dynamical compression of the heart in all patients. After surgery, all patients showed improvement on postoperative CMR. Five of the 6 (83%) patients had complete relief of right ventricular compression, and 5 of the 6 (83%) patients had relief of left atrial compression. The degree of antero-posterior chest wall narrowing was also markedly improved, with an average postoperative vs preoperative Haller index of 3.2 (range, 2.7-3.8) vs 5.0 (range, 4.0-5.9). CONCLUSIONS After surgical correction of pectus excavatum with the sternal eversion technique, CMR demonstrates improvement in both anatomical chest wall contour and cardiac performance. Sternal eversion provides the most complete anatomical correction and greatest relief of internal cardiac compression. We recommend CMR as the definitive modality for evaluation of patients with pectus excavatum, as this modality shows that the primary underlying physiological abnormality in pectus excavatum is cardiac compression.

Comparing velour versus silicone interfaces at the driveline exit site of HeartMate II devices: infection rates, histopathology, and ultrastructural aspects.

BACKGROUND Driveline exit site (DLES) infection is a major complication of ventricular assist devices (VADs). Differences in the sheath material interfacing with exit site tissue appear to affect healing time and infection risk more than site hygiene, but the mechanistic basis for this is not clear. METHODS Health record data from Utah Artificial Heart Program patients with HeartMate II (HMII) devices implanted from 2008 to 2012 were retrospectively reviewed, with particular attention to interface type, incorporation (healing) time, and infections. Tissue samples from the DLES were collected at the time of VAD removal in a small subset. These samples were examined by routine histology and environmental scanning electron microscopy (ESEM). RESULTS Among 57 patients with sufficient data, 15 had velour interfaces and 42 had silicone. Indications for and duration of support were similar between the groups. The silicone group had shorter incorporation time (45 ±22 vs. 56 ±34 days, P=.17) and fewer DLES infections (20% vs. 1.7%, P=.026, for patient infections and 0.0340 vs. 0.166, P=.16, for infections per patient-year). Tissues from five patients, three with velour, were examined. Velour interfaces demonstrated more hyperkeratosis, hypergranulosis, and dermal inflammation. By ESEM, the silicone driveline tracts appeared relatively smooth and flat, whereas the velour interface samples were irregular with deep fissures and globular material adhering to the surface. CONCLUSIONS Using the silicone portion of the HMII driveline at the DLES was associated with fewer infections and a trend toward faster healing in this small retrospective series. Whether the intriguing microscopic differences directly account for this needs further study on a larger scale.

Black pigmented aortic valve and sinus of Valsalva caused by life-long minocycline therapy.

Minocycline, a derivative of tetracycline, is a broad-spectrum antibiotic used in the treatment of various infections. Black discolouration of the skin, teeth, bones and the thyroid gland are sequelae of long-term minocycline therapy. We report an unusual case of minocycline-induced pigmentation of the aortic valve and sinuses of Valsalva.

Antibiotic-Impregnated Beads for the Treatment of Aortic Graft Infection

Infection of a prosthetic graft after replacement of the ascending aorta is an uncommon but life-threatening complication of surgery. We report the use of antibiotic-impregnated calcium sulfate beads in a patient with ascending aortic graft infection to provide localized, high-dose therapy to the infected region. Perigraft placement of antibiotic beads provides an alternative method for the treatment of aortic graft infection.

Predicting readmission risk shortly after admission for CABG surgery

Reducing preventable hospital readmissions after coronary artery bypass graft (CABG) surgery has become a national priority. Predictive models can be used to identify patients at high risk for readmission. However, the majority of the existing models are based on data available at discharge. We sought to develop a model to predict hospital readmission using data available soon after admission for isolated CABG surgery.

Radiopaque Marker Addition During Aortic Root Replacement With the Use of a Freestyle Porcine Bioprosthesis

Aortic root replacement is indicated for aortic root aneurysm, small aortic root, and most root abscesses. This report describes the placement of a radiopaque marker during aortic root replacement using a Freestyle porcine bioprosthesis. This marker is a useful landmark during fluoroscopy for transcatheter valve-in-valve aortic valve replacement in the event of bioprosthesis degeneration.

Evaluation of new generation loop recorders placed during surgical ablation for atrial fibrillation

Current postsurgical atrial fibrillation (AF) ablation guidelines encourage serial rhythm evaluation; however, traditional Holter monitoring may be cumbersome for patients and yield limited data. An implantable loop recorder (LR) may provide increased data on the incidence of postablation arrhythmias. We sought to evaluate the use of a new generation LR implanted during surgical AF ablation.