Masashi Kai

Surgery for acute type A aortic dissection in octogenarians is justified

OBJECTIVE Surgery in octogenarians with acute type A aortic dissection is commonly avoided or denied because of the high surgical morbidity and mortality reported in elderly patients. We sought to compare clinical and quality of life outcomes between octogenarians and those aged less than 80 years who underwent surgical repair at New York Medical College. METHODS A total of 101 cases of acute type A aortic dissection repair between July 2005 and December 2011 were retrospectively analyzed, comparing 21 octogenarians with 80 concurrent patients aged less than 80 years. All patients underwent corrective surgery (ascending/hemiarch replacement in 71; Bentall in 22; David procedure in 2; Wheat procedure in 4; total arch replacement in 2) using deep hypothermic circulatory arrest. During follow-up, the RAND 36-Item Short Form Health Survey Questionnaire was used to assess quality of life. RESULTS Octogenarians (average, 85 years; range, 80-91 years) were compared with the younger group (average, 60 years; range, 30-79 years). The 2 groups had similar preoperative characteristics, but the younger group experienced more malperfusion (40% vs 9%, P = .002), were more likely to have undergone a Bentall procedure (26% vs 5%, P = .04), and had longer circulatory arrest times (20 ± 7 minutes vs 16 ± 9 minutes, P = .03). The overall hospital mortality was 9% (9/101). Among octogenarians, there were no hospital deaths, no late deaths during follow-up (mean, 17 months; range, 1-59 months), and emotional health scores were better than those of the younger patients (P = .04). CONCLUSIONS Surgery for acute type A aortic dissection should be offered to octogenarians because excellent surgical and quality of life outcomes can be achieved even in this elderly population.

Peripheral venoarterial extracorporeal membrane oxygenation improves survival in myocardial infarction with cardiogenic shock

Age (y) 61 14 Women 7 (33%) Hypertension 12 (57%) Diabetes 9 (43%) Hyperlipidemia 11 (52%) Smoker 7 (33%) Renal failure 1 (5%) COPD 2 (10%) Despite early revascularization, cardiogenic shock complicating acute myocardial infarction carries high mortality. Intra-aortic balloon pump (IABP) support was recently found to confer no mortality benefit over medical therapy in the Intraaortic Balloon Pump in Cardiogenic Shock II (IABP-SHOCK II) trial. This communication focuses on our experience with venoarterial (VA) peripheral extracorporeal membrane oxygenation (pECMO) in patients with acute myocardial infarction complicated by cardiogenic shock. PVD 4 (19%) TIA/stroke 2 (10%) History of MI 16 (76%) History of CHF 8 (38%) Cardiogenic shock 21 (100%) Previous PCI 11 (52%) Previous CABG 4 (19%) Ventricular tachycardia/fibrillation 11 (52%) Cardiac arrest requiring resuscitation 10 (48%) IABP or Impella support before ECMO 21 (100%) Predicted mortality from APACHE4 score 38% 16% Catheterization laboratory 45% 16% Operating room 36% 16%

Cardiac Transplantation in the New Era.

The prevalence of heart failure continues to rise due to the aging population and longer survival of people with conditions that lead to heart failure, eg, hypertension, diabetes, and coronary artery disease. Although medical therapy has had an important impact on survival of patients and improving quality of life, heart transplantation remains the definitive therapy for patients that eventually deteriorate. Since the first successful heart transplantation in 1967, significant improvements have been made regarding donor and recipient selection, surgical techniques, and postoperative care. However, the number of potential organ donors has not changed and the growing number of patients in need for transplantation has resulted an increase in waiting list time, and the need for mechanical support. To overcome this issue, the United Network for Organ Sharing implemented an allocation system to prioritize the sickest patients on the list to receive organs. Despite the careful selection of patients, pretransplant immunological screening, and multidrug immunosuppressive regimens, acute and chronic rejections occur and potentially limit graft and patient survival. Treatment for rejection largely depends on the type of rejection, the presence of hemodynamic compromise, and time after transplantation. The limiting factor for long-term graft survival is allograft vasculopathy, an immune-mediated process causing diffuse narrowing of the coronary arteries. Percutaneous coronary intervention and coronary artery bypass surgery are often not an option for this vasculopathy due to the lack of focal lesions, and retransplantation is the only option in appropriate patients.

Venoarterial extracorporeal membrane oxygenation for right heart failure complicating left ventricular assist device use

From 15% to 25% of patients have right heart failure (RHF) develop after left ventricular (LV) assist device (LVAD) placement, significantly increasing morbidity and mortality. Right ventricular (RV) assist devices (RVADs) may support RV function, but they have significant limitations. We describe a novel management strategy of using peripheral venoarterial extracorporeal membrane oxygenation (ECMO), configured for easy explantation, that may improve RV recovery and reduce mortality and morbidity.